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Empire PPO for EmpireBlue

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					               City of New York Benefits Program
                         Group 157800




                                                                                                          EPO
            Services provided by Empire HealthChoice Assurance, Inc., a licensee of the Blue Cross and Blue Shield Association,
                                    an association of independent Blue Cross and Blue Shield Plans.
   Blue Cross, Blue Shield, the Cross and Shield symbols and BlueCard are registered marks of the Blue Cross and Blue Shield Association.
              AT&T Direct is a registered mark of AT&T. Weight Watchers is a registered mark of Weight Watchers International.
                 o
The Butterfly, 360 Health, HealthLine Nurse Access and HealthLine Recorded Topics, and Empire Pharmacy Management are service marks of
                                                   Empire HealthChoice Assurance, Inc.
                                                                 09/2005
Welcome!
Welcome to Empire’s EPO. With Empire BlueCross BlueShield, you have access to great coverage, flexibility and all the
advantages of quality care. This benefits book explains exactly how you access healthcare services, what your health plan covers
and how we can help you make the most of your plan.
YOUR EPO – A SMART WAY TO GET HEALTHCARE
      Your EPO, or Exclusive Provider Organization, is a group healthcare plan available to you through an insurance policy issued
      and underwritten by Empire BlueCross BlueShield. The EPO offers a network of healthcare providers available to you through
      Empire. If you think about your town, it includes doctors, hospitals, laboratories and other medical facilities that provide
      healthcare services–that’s what we mean by healthcare “providers.” Some healthcare providers contract with health plans like
      Empire to provide services to members as part of the plan’s “network.”
      With Empire’s EPO, when you need healthcare services, you are free to get care from any provider participating in
      Empire’s network.


WHAT’S THE EPO ADVANTAGE?

      When you use Empire’s network to access healthcare, you get:
            •     A comprehensive Web site, www.empireblue.com/nyc for fast, personalized, secure information
            •     Among the largest network of doctors and hospitals in New York State
            •     Providers that are continuously reviewed for Empire’s high standards of quality
            •     Minimal out-of-pocket costs for preventive care, behavioral healthcare and a wide variety of hospital and medical
                  services when you stay in-network
            •     Easy to use – no claim forms to file when you stay in-network
            •     Coverage for you and your family when traveling or temporarily living outside of Empire’s service area

HOW TO USE THIS GUIDE

      This Guide gives you an overview of the features and benefits of your EPO. Use it as a reference to find out what’s covered,
      what your costs are, and how to get healthcare services any time you or a covered family member need them.*
      You’ll find the information you need divided into sections. Here’s a quick reference:


                IF YOU ARE LOOKING FOR …                                           YOU’LL FIND IT IN                         ON PAGE

        •       HOW THE PLAN WORKS                                                 USING YOUR EPO                                 6


        •       WHAT’S COVERED                                                     COVERAGE                                      13


        •       PRECERTIFICATION AND HEALTH INFORMATION                            HEALTH MANAGEMENT                             29


        •       HOW TO FILE A CLAIM, THE MEANING OF HEALTHCARE TERMS,              DETAILS AND DEFINITIONS                       36
                AND YOUR LEGAL RIGHTS




*
    This Guide describes only the highlights of your medical coverage. It does not attempt to cover all the details. Additional details are
    provided in the plan documents and insurance and/or service contracts, which legally govern the plan. In the event of any discrepancy
    between this Guide and the plan documents, the plan documents will govern.


                                                          www.empireblue.com                                                                  1
Manage Your Healthcare Online!

REGISTER NOW TO DO IT ON THE WEB!

    Go to www.empireblue.com/nyc where you can securely manage your health plan 24 hours a day, 7 days a week. Here’s what
    you can do:
    •   Check status of claims                          •   Access pharmacy information and services
    •   Search for doctors and specialists              •   Print plan documents
    •   Update your member profile                      •   Receive information through your personal “Message Center”
    •   Get health information and tools with My        •   Visit the Pharmacy
        Health powered by WebMD
    Plus much more …


HERE’S WHAT YOU’LL NEED TO DO

    All members of your family 18 or older must register separately:
    • Go to www.empireblue.com/nyc                      • Follow the simple registration instructions
    • Click on the Member tab and choose
        “Register”

ASSISTANCE IS A CLICK AWAY

    Use the Click-to-Talk feature to contact us three different ways:
        • E-mail: You can e-mail us with a question 24 hours a day, 7 days a week, and a customer service representative will
             e-mail an answer back to you through your Message Center.
        • Collaboration: Our representative will call you while you are online and navigate the site along with you. We can
             even take control of your mouse, making it easier to answer your questions.
        • Call Back: You can request that a representative contact you with assistance.


GET PERSONALIZED HEALTH INFORMATION – INCLUDING YOUR HEALTH IQ

    Click on MY HEALTH from your secure homepage after you register to receive the following features:
        • Take the Health IQ test and compare your score to others in your age group
        • Find out how to improve your score – and your health – online
        • Find out how to take action against chronic and serious illnesses
        • Get health information for you and your family.

YOUR PRIVACY IS PROTECTED

    Your information is protected by one of the most advanced security methods available.




                            Register today to experience hassle-free service!
                                       www.empireblue.com/nyc


2                                                   www.empireblue.com
Your EPO Guide

Introduction
  GETTING ANSWERS YOUR WAY..................................................................................................................................4
  YOUR IDENTIFICATION CARD ......................................................................................................................................5
Using Your EPO
  KNOW THE BASICS ........................................................................................................................................................6
  YOUR BENEFITS AT A GLANCE....................................................................................................................................8
Coverage
  DOCTOR’S SERVICES..................................................................................................................................................13
  EMERGENCY CARE .....................................................................................................................................................14
  MATERNITY CARE AND INFERTILITY TREATMENT ..................................................................................................16
  HOSPITAL SERVICES...................................................................................................................................................18
  DURABLE MEDICAL EQUIPMENT AND SUPPLIES ....................................................................................................20
  SKILLED NURSING AND HOSPICE CARE...................................................................................................................21
  HOME HEALTH CARE...................................................................................................................................................22
  PHYSICAL, OCCUPATIONAL, SPEECH OR VISION THERAPY .................................................................................23
  BEHAVIORAL HEALTHCARE .......................................................................................................................................24
                                                            SM
  EMPIRE PHARMACY MANAGEMENT ......................................................................................................................25
  EXCLUSIONS AND LIMITATIONS ................................................................................................................................27
Health Management
  EMPIRE’S MEDICAL MANAGEMENT PROGRAM .......................................................................................................29
  NEW MEDICAL TECHNOLOGY ....................................................................................................................................32
  CASE MANAGEMENT ...................................................................................................................................................32
  HEALTHY LIVING PROGRAMS ....................................................................................................................................33
  360° HEALTHSM – EMPIRE’S HEALTH SERVICES PROGRAMS ................................................................................34
Details and Definitions
  ELIGIBILITY ...................................................................................................................................................................36
  CLAIMS ..........................................................................................................................................................................38
  COMPLAINTS, APPEALS AND GRIEVANCES.............................................................................................................40
  ENDING AND CONTINUING COVERAGE ....................................................................................................................44
  YOUR ERISA RIGHTS...................................................................................................................................................55
  NOTICE OF PRIVACY PRACTICES..............................................................................................................................57
  HIPAA PRIVACY REQUIREMENTS ..............................................................................................................................61
  DEFINITIONS.................................................................................................................................................................63
  HEALTHLINE AUDIOTAPE TOPICS .............................................................................................................................67




                                                                           www.empireblue.com                                                                                           3
    Introduction
Getting Answers Your Way
Empire gives you more choices for contacting us with your customer service questions. Use the Internet, phone or mail to
get the information you need, when you need it.
ON THE INTERNET
    Do you have customer service inquiries and need an instant response? Visit www.empireblue.com/nyc.
    At Empire, we understand that getting answers quickly is important to you. Most benefit, claims or membership questions can
    be addressed online quickly, simply and confidentially.
    Nervous about using your PC for important healthcare questions or transactions? We’ve addressed that too! Just “click to
    talk” to a representative or send us an e-mail.
BY TELEPHONE
                          WHAT                                     WHY                                       WHERE
      MEMBER SERVICES                           For questions about your benefits, claims     1-800-767-8672
                                                or membership                                 TDD for hearing impaired:
                                                                                              1-800-241-6895
                                                                                              8:30 a.m. to 5:00 p.m. Monday – Friday
      ATT SERVICIOS PARA IDIOMAS                Si usted no habla inglés                      1-800-767-8672
      EXTRANJEROS                                                                             Por favor permanezca en la línea y
                                                                                              espere que la grabación termine. Un
                                                                                              representante de servicios a los
                                                                                              miembros contestará la línea y le
                                                                                              conectará con un traductor
                                                                                              9:00 a.m. a 5:00 p.m. de Lunes – Viernes
                 ®
      BLUECARD PPO PROGRAM                      Get network benefits while you are away       1-800-810-BLUE (2583)
                                                from home
                                                                                              www.bcbs.com
                                                Locate a PPO provider outside Empire’s        24 hours a day, 7 days a week
                                                network service area
      MEDICAL MANAGEMENT PROGRAM                Precertification of hospital admissions and   1-800-982-8089
                                                certain surgeries, therapies, diagnostic      8:30 a.m. to 5:00 p.m. Monday -– Friday
                                                tests and medical supplies
                     SM
      HEALTHLINE NURSE ACCESS AND               Speak with a specially trained nurse to get   1-877-TALK-2RN (825-5276)
      RECORDED TOPICS                           health information and instructions on how    24 hours a day, 7 days a week
                                                to listen to the tapes
      BEHAVIORAL HEALTHCARE                     To locate a participating behavioral          1-800-626-3643
      MANAGEMENT                                healthcare provider in your area              NON-EMERGENCY CARE
                                                Precertification of mental health and         8:30 a.m. to 5:00 p.m. Monday – Friday
                                                                                              EMERGENCY CARE
                                                alcohol/substance abuse care
                                                                                              24 hours a day, 7 days a week
      EMPIRE PHARMACY MANAGEMENT                Information about the program                 1-800-342-9816
      PROGRAM                                                                                 TDD for hearing impaired:
                                                Locate a participating retail pharmacy
                                                                                              1-800-241-6895
                                                Obtain a complete drug formulary list         7:00 a.m. to 10:00 p.m. Monday – Friday
                                                                                              9:00 a.m. to 9:00 p.m. Saturday
                                                                                              9:00 a.m. to 5:30 p.m. Sunday
      VISION CARE                               To find a participating Davis vision care     1-877-923-2847
                                                network provider in your area                 8:00 a.m. to 8:00 p.m. Monday – Friday
                                                                                              9:00 a.m. to 4:00 p.m. Saturday
      FRAUD HOTLINE                             Help prevent health insurance fraud           1-800-I-C-FRAUD (423-7283)
                                                                                              9:00 a.m. to 5:00 p.m. Monday – Friday

IN WRITING
    Empire BlueCross BlueShield
    EPO Member Services
    P.O. Box 1407
    Church Street Station
    New York, NY 10008-1407


4                                                   www.empireblue.com
Your Identification Card
Empire BlueCross BlueShield has created a whole new kind of identification card to make accessing your healthcare as easy as
possible. The Empire BlueCross BlueShield I.D. card is a single card that you can use for all your Empire health insurance services,
as it shows each of the plans or programs you’re enrolled in. Always carry it and show it each time you receive healthcare services
from a network provider. Every covered member of your family will get his or her own card.

The information on your card includes your name, identification number, and various co-payment amounts.




To make it easier for you to use your new card, following are answers to some frequently asked questions:

Q: Why is Empire issuing this kind of I.D. card?
A: Empire’s card has all the information providers need to know to serve our members’ healthcare needs. Our new design
   eliminates the need for you to carry multiple cards.

Q: What do the icons in the upper right hand corner of the card mean?
A: The icons are illustrations of the plan(s) that you’ve enrolled in. The first icon shows that you’re enrolled in the EPO.
   Your EPO icon will also have a PPO suitcase logo on it, which means that you have access to the BlueCard PPO
   network (see page 9 for more information). The other icons show which additional plans or programs you are enrolled
   in—pharmacy, dental or vision. It’s easy to see what coverage you have!

Q: Why does each family member get a separate I.D. card?
A: By giving your family members their own card with their own name on it, providers know right away that each family
   member is covered by the plan – even dependents. If someone in your family happens to forget the card, he or she can
   still use another family member’s card. (In a few instances, family members in some groups will receive two I.D. cards
   in the member’s name only. These cards will be used for all family members.)

Q: How can I replace a lost I.D. card?
A: Visit www.empireblue.com/nyc or call Member Services.

We’ve tried to anticipate most of your questions, but please get in touch with us if you have more specific issues.




                                                       www.empireblue.com                                                          5
    Using Your EPO
USE YOUR EPO TO YOUR BEST ADVANTAGE
    Your health is valuable. Knowing how to use your EPO to your best advantage will help ensure that you receive high quality
    healthcare – with maximum benefits. Here are three ways to get the most from your coverage:
        •    BE SURE YOU KNOW WHAT’S COVERED BY THE PLAN. That way, you and your doctor are better able to
             make decisions about your healthcare. Empire will work with you and your doctor so that you can take advantage of
             your healthcare options and are aware of limits the plan applies to certain types of care.
        •    PLEASE REMEMBER TO PRECERTIFY hospital, ambulatory surgery (for medically necessary
             cosmetic/reconstructive surgery, outpatient transplants, ophthalmological or eye-related procedures) and other facility
             admissions, maternity care, certain diagnostic tests and procedures, and certain types of equipment and supplies to
             ensure maximum benefits. Precertification gives you and your doctor an opportunity to learn what the plan will cover
             and identify treatment alternatives and the proper setting for care—for instance, a hospital or your home. Knowing
             these things in advance can help you save time and money. If you fail to precertify when necessary, your benefits may
             be reduced or denied.
        •    ASK QUESTIONS about your healthcare options and coverage. To find answers, you can:
        −    Read this Guide.
        −    Call Member Services when you have questions about your EPO benefits in general or your benefits for a specific
             medical service or supply.
        −    Call HealthLineSM Nurse Access and Recorded Topics – available to members 24 hours a day to get recorded general
             health information or to speak to a nurse to discuss healthcare options and more.
    Talk to your provider about your care, learn about your benefits and your options, and ask questions. Empire is here to work
    with you and your provider to see that you get the best benefits while receiving the quality healthcare you need.

KNOW THE BASICS
    The key to using your EPO plan is understanding how benefits are paid. To receive benefits, you must use a provider in the
    Empire network or one covered through the BlueCard PPO Program. There are no out-of-network benefits under this program.
    You can view and print up-to-date information about your plan or request that information be mailed to you by visiting
    www.empireblue.com/nyc

IN-NETWORK SERVICES
    In-network services are healthcare services provided by a doctor, hospital or healthcare facility that has been selected by
    Empire or another Blue Cross and/or Blue Shield plan to provide care to our EPO members. With in-network care, you get
    these advantages:
        •    CHOICE – You can choose any participating provider from the largest network of doctors and hospitals in New York
             State or across the country from providers participating in the BlueCard PPO® network through local Blue Cross and
             Blue Shield plans.
        •    FREEDOM – You do not need a referral to see a specialist, so you direct your care.
        •    LOW COST – Benefits are paid after a small co-payment for office visits and many other services.
        •    BROAD COVERAGE – Benefits are available for a broad range of healthcare services, including visits to specialists,
             physical therapy, and home healthcare.
        •    CONVENIENCE – Usually, there are no claim forms to file.

WHERE TO FIND NETWORK PROVIDERS
    Empire’s network gives you access to providers within the plan’s operating area of 28 eastern New York State counties. See
    “operating area” in the Details and Definitions section for a listing of counties.
    To locate a provider in Empire’s operating area, visit www.empireblue.co/nyc. You can search for providers by name, address,
    language spoken, specialty and hospital affiliation. The search results include a map and directions to the provider’s office. Or,
    ask your Benefits Administrator to see Empire’s Provider Directory. You can also request that a directory be mailed to you free
    of charge by calling Member Services at 1-800-767-8672



6                                                     www.empireblue.com
YOUR EPO BENEFITS OUT-OF-AREA
      When you live or travel outside of Empire’s operating area, Empire’s EPO provides benefits through the following programs:

      BlueCard® PPO Program
      Nationwide, Blue Cross and Blue Shield plans have established Preferred Provider Organization (PPO) networks of physicians,
      hospitals and other healthcare providers. As an EPO member, you have access to these networks through the BlueCard PPO
      Program. By presenting your Empire I.D. card to a provider participating in the BlueCard PPO Program, you receive the same
      benefits as you would receive from an Empire network provider. The suitcase logo on your I.D. card indicates that you are a
      member of the BlueCard PPO Program. Call 1-800-810-BLUE (2583) or visit www.bcbs.com to locate participating providers.

      BlueCard® Worldwide
      Need emergency services when traveling outside the United States? The BlueCard Worldwide program provides coverage
      through an international network of hospitals, doctors and other healthcare providers. With this program, you’re assured of
      receiving care from licensed healthcare professionals. The program also assures that at least one staff member at the hospital
      will speak English, or the program will provide translation assistance.
      See the Details and Definitions section for more information on the BlueCard and BlueCard Worldwide programs.

                                            Here’s an example of how in-network works.

                                                                                                             IN-NETWORK

        PROVIDER’S CHARGE                                                         $500

        ALLOWED AMOUNT                                                            $400

        PLAN PAYS PROVIDER                                                        $385

        YOU PAY PROVIDER                                                          $15 co-payment

        CO-PAYMENT (for office visits and certain covered services)               $15 per visit

                                                             *                    $250 per admission
        CO-PAYMENT (for hospital inpatient admissions)


        CO-PAYMENT (for emergency room)                                           $35 per visit (waived if admitted to hospital within 24 hours)

        COINSURANCE                                                               $0

        ANNUAL OUT-OF-POCKET COINSURANCE MAXIMUM                                  N/A

        LIFETIME MAXIMUM                                                          Unlimited




*
    Up to $625 maximum per contract, per year. Co-payment is waived if you are readmitted to any network hospital within 90 days of discharge.



                                                                 www.empireblue.com                                                                7
Your Benefits At A Glance
     Empire’s EPO provides a broad range of benefits to you and your family. Following is a brief overview of your coverage. See
     the Coverage section for more details.
     When you see the telephone icon, you’ll know that you or your doctor will need to precertify these services with Empire’s
     Medical Management Program. In most cases, it is your responsibility to call. In some cases the provider or supplier of
     services needs to call. See the Health Management section for details.

                       HOME, OFFICE/OUTPATIENT CARE                                                              YOU PAY

       HOME/OFFICE VISITS                                                         $15 co-payment per visit


       SPECIALIST VISITS                                                          $15 co-payment per visit

                                 *
       CHIROPRACTIC CARE                                                          $15 co-payment per visit

                                                     **
       SECOND OR THIRD SURGICAL OPINION                                           $15 co-payment per visit

       DIABETES EDUCATION AND MANAGEMENT                                          $15 co-payment


       ALLERGY TESTING and TREATMENT                                              $15 co-payment per visit, (co-payment waived for treatment)

       DIAGNOSTIC PROCEDURES
       • X-rays and other imaging                                                 $0
       • Radium and Radionuclide therapy                                          $0

       • MRIs/MRAs***                                                             $0
                                                                                  $0
       • Nuclear cardiology services ***
                                                                                  $0
       • PET/CAT scans***
       • Laboratory tests                                                         $0

       SURGERY                                                                    $0

       PRE-SURGICAL TESTING                                                       $0

       ANESTHESIA                                                                 $0

       CHEMOTHERAPY, RADIATION                                                    $0

       KIDNEY DIALYSIS                                                            $0


       SECOND OR THIRD MEDICAL OPINION FOR CANCER                                 $15 co-payment per visit
       DIAGNOSIS

       CARDIAC REHABILITATION                                                     $15 co-payment




*   It is the provider’s responsibility to call Empire for precertification of all in-network chiropractic care after the fifth visit.
** The co-payment is waived if the surgical opinion is arranged through Empire’s Medical Management Program.
*** It is the provider’s responsibility to call Empire for precertification of all in-network PET/ CAT scans, MRIs/ MRAs and Nuclear Cardiology services.



8                                                              www.empireblue.com
                        PREVENTIVE CARE                                                       YOU PAY

ANNUAL PHYSICAL EXAM
• One per calendar year                                           $15 co-payment per visit

DIAGNOSTIC SCREENING TESTS
• Cholesterol: 1 every 2 years                                    $0
• Diabetes (if pregnant or considering pregnancy)
                                                                  $0
• Colorectal cancer
  – Fecal occult blood test if age 40 or over: 1 per year         $0
  – Sigmoidoscopy if age 40 or over: 1 every 2 years
• Routine Prostate Specific Antigen (PSA) in asymptomatic males   $0
  – Over age 50-: 1 every year
  – Between ages 40-49 if risk factors exist: 1 per year
  – If prior history of prostate cancer, PSA at any age
• Diagnostic PSA: 1 per year                                      $0

WELL-WOMAN CARE
• Office visits                                                   $15 co-payment per visit
• Pap smears                                                      $0
• Bone Density testing and treatment                              $0
• Mammogram (based on age and medical history)
  – Ages 35 through 39 – 1 baseline                               $0
  – Age 40 and older – 1 per year

WELL-CHILD CARE
• Office visits and associated lab services provided within       $0
  5 days of office visit
  – Newborn: 1 in-hospital exam at birth
  – Birth to age 1: 7 visits
  – Ages 1 through 2: 3 visits
  – Ages 3 through 6: 4 visits
  – Ages 7 up to 19th birthday: annual visits
• Immunizations                                                   $0
                       EMERGENCY CARE                                                         YOU PAY

EMERGENCY ROOM                                                    $35 co-payment per visit (waived if admitted to the same hospital
                                                                  within 24 hours)

PHYSICIAN’S OFFICE                                                $15 co-payment per visit

AIR AMBULANCE
• Transportation to nearest acute care hospital for emergency     $0
  inpatient admissions

AMBULANCE
• Local professional ground ambulance to nearest hospital         $0 up to the allowed amount. You pay the difference between the
                                                                  allowed amount and the total charge.




                                                      www.empireblue.com                                                          9
                MATERNITY CARE AND INFERTILITY TREATMENT                                                            YOU PAY

        PRENATAL AND POSTNATAL CARE (In doctor’s office)                             $0

        LAB TESTS, SONOGRAMS AND OTHER DIAGNOSTIC                                    $0
        PROCEDURES

        ROUTINE NEWBORN NURSERY CARE (In hospital)                                   $0

        OBSTETRICAL CARE (In hospital)                                               $0


        INFERTILITY TREATMENT                                                        $0

        OBSTETRICAL CARE (In birthing center)                                        $0

                                                      *
                             HOSPITAL SERVICES                                                                      YOU PAY

        SEMIPRIVATE ROOM AND BOARD                                                   $250 co-payment per admission


        ANESTHESIA AND OXYGEN                                                        $0


        CHEMOTHERAPY AND RADIATION THERAPY                                           $0


        CARDIAC REHABILITATION                                                       $15 co-payment per outpatient visit


        DIAGNOSTIC X-RAYS AND LAB TESTS                                              $0


        DRUGS AND DRESSINGS                                                          $0


        GENERAL, SPECIAL AND CRITICAL NURSING CARE                                   $0


        INTENSIVE CARE                                                               $0


        KIDNEY DIALYSIS                                                              $0


        PRESURGICAL TESTING                                                          $0

        SERVICES OF LICENSED PHYSICIANS AND SURGEONS                                 $0

                                               **
        SURGERY (Inpatient and outpatient)                                           $0




*
     Does not include inpatient or outpatient behavioral healthcare or physical therapy/rehabilitation. See the Coverage section for a description of these
     benefits. Outpatient hospital surgery and inpatient admissions need to be precertified.
**
     For a second procedure performed during an authorized surgery through the same incision, Empire pays for the procedure with the highest allowed
     amount. For a second procedure done through a separate incision, Empire will pay the allowed amount for the procedure with the highest allowance
     and up to 50% of the allowed amount for the other procedure.



10                                                               www.empireblue.com
                DURABLE MEDICAL EQUIPMENT AND SUPPLIES                                                         YOU PAY

        DURABLE MEDICAL EQUIPMENT                                                   $0
        (i.e., hospital-type bed, wheelchair, sleep apnea monitor)

        ORTHOTICS                                                                   $0

        PROSTHETICS (i.e., artificial arms, legs, eyes, ears)                       $0

        MEDICAL SUPPLIES (i.e., catheters, oxygen, syringes)                        $0

                                             *
        NUTRITIONAL SUPPLEMENTS (enteral formulas and modified                      $0
        solid food products)

                     SKILLED NURSING AND HOSPICE CARE                                                          YOU PAY

        SKILLED NURSING FACILITY
        • Up to 60 days per calendar year                                           $0

        HOSPICE
        • Up to 210 days per lifetime                                               $0

                                HOME HEALTH CARE                                                               YOU PAY

        HOME HEALTH CARE
        • Up to 200 visits per calendar year (a visit equals 4 hours of care)       $0
        • Home infusion therapy
                                                                                    $0

          PHYSICAL, OCCUPATIONAL, SPEECH OR VISION THERAPY                                                     YOU PAY

        PHYSICAL THERAPY AND REHABILITATION
        • Up to 30 days of inpatient service per calendar year                      $250 co-payment per admission
        • Up to 30 visits combined in home, office or outpatient facility per
                                                                                    $15 co-payment per visit
          calendar year
                                                              **
        OCCUPATIONAL, SPEECH, VISION THERAPY
        • Up to 30 visits per person combined in home, office or                    $15 co-payment per visit
          outpatient facility per calendar year

                               MENTAL HEALTH CARE                                                              YOU PAY

        OUTPATIENT
        • Up to 20 visits per calendar year                                         $25 co-payment per visit

        INPATIENT
        • Up to 30 days per calendar year                                           $250 co-payment per admission
        • Up to 30 visits from mental health care professionals per calendar
          year                                                                      $0

                ALCOHOL OR SUBSTANCE ABUSE TREATMENT                                                           YOU PAY

        OUTPATIENT
        • Up to 60 visits per calendar year, including up to 20 visits for family   $0
          counseling

        INPATIENT
        • Up to 7 days detoxification per calendar year                             $250 co-payment per admission
        • Up to 30 days rehabilitation per calendar year
                                                                                    $250 co-payment per admission




*
     $2,500 limit for modified solid food products in any continuous 12-month period.
**
     Vision therapy does not require precertification.



                                                                   www.empireblue.com                                    11
                 PHARMACY (RETAIL* AND MAIL ORDER)                                    YOU PAY

     RETAIL
     • Generic                                             $10 co-payment per 30 day supply
     • Brand
                                                           $25 co-payment per 30 day supply
     • Non-Formulary
                                                           $50 co-payment per 30 day supply

     MAIL ORDER
     • Generic                                             $10 co-payment per 30 day supply
     • Brand                                               $25 co-payment per 30 day supply
     • Non-Formulary                                       $50 co-payment per 30 day supply




* Benefit Maximum of $3,000 per person per calendar year. Benefits in excess of $3,000 are subject to
a 50% coinsurance.




12                                             www.empireblue.com
 Coverage
Doctor’s Services
When you need to visit your doctor or a specialist, Empire makes it easy. By staying in-network, you pay only a small co-payment.
There are no claim forms to fill out, for X-rays, blood tests or other diagnostic procedures—as long as they are requested by the
doctor and done in the doctor’s office or a network facility. For in-network allergy testing there is only a small co-payment. In-
network visits for ongoing allergy treatment are covered in full. There are no benefits for out-of-network services.
     Tips For Visiting Your Doctor
          • When you make your appointment, confirm that the doctor is an Empire network provider and that he/she is
               accepting new patients.
          • Arrange ahead of time to have pertinent medical records and test results sent to the doctor.
          • If the doctor sends you to an outside lab or radiologist for tests or X-rays, visit www.empireblue.com/nyc or call
               Member Services to confirm that the supplier is in Empire’s network. This will ensure that you receive maximum
               benefits.
Ask about a second opinion any time that you are unsure about surgery or a cancer diagnosis. Second and third opinions for surgery
are paid in full when arranged through Empire’s Medical Management Program. The specialist who provides the second or third
opinion cannot perform the surgery. To confirm a cancer diagnosis or course of treatment, second or third opinions are paid at the
in-network level, even if you use an out-of-network specialist, as long as your participating doctor provides a written referral to a
non-participating specialist.

    What’s Covered
    Covered services are listed in Your Benefits at a Glance section. Following are additional covered services and limitations:
       • Consultation requested by the attending physician for advice on an illness or injury
       • Diabetes supplies prescribed by an authorized provider:
            − Blood glucose monitors, including monitors for the legally blind
            − Testing strips
            − Insulin, syringes, injection aids, cartridges for the legally blind, insulin pumps and appurtenances, and insulin
                  infusion devices
            − Oral agents for controlling blood sugar
            − Other equipment and supplies required by the New York State Health Department
            − Data management systems
       • Diabetes self-management education and diet information, including:
            − Education by a physician, certified nurse practitioner or member of their staff:
                  At the time of diagnosis
                  When the patient’s condition changes significantly
                  When medically necessary
            − Education by a certified diabetes nurse educator, certified nutritionist, certified dietitian or registered dietitian
                  when referred by a physician or certified nurse practitioner. This benefit may be limited to a group setting when
                  appropriate.
            − Home visits for education when medically necessary
       • Diagnosis and treatment of degenerative joint disease related to temporomandibular joint (TMJ) syndrome that is not
            a dental condition
       • Diagnosis and treatment for orthognathic surgery that is not dental in nature
       • Medically necessary hearing examinations
       • Foot care and orthotics associated with disease affecting the lower limbs, such as severe diabetes, which requires care
            from a podiatrist or physician.
       • Chiropractic care (your provider must call Empire’s Medical Management Program to precertify services after the
            fifth visit)




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     What’s Not Covered
     The following medical services are not covered:
         • Routine foot care, including care of corns, bunions, calluses, toenails, flat feet, fallen arches, weak feet and chronic
              foot strain
         • Symptomatic complaints of the feet except capsular or bone surgery related to bunions and hammertoes
         • Orthotics for treatment of routine foot care
         • Routine vision care
         • Routine hearing exams
         • Hearing aids and the examination for their fitting
         • Services such as laboratory, X-ray and imaging, and pharmacy services as required by law from a facility in which
              the referring physician or his/her immediate family member has a financial interest or relationship
         • Services given by an unlicensed provider or performed outside the scope of the provider’s license.



Emergency Care
IF YOU NEED EMERGENCY CARE
     Should you need emergency care, your plan is there to cover you. Emergency care is covered in the hospital emergency room.
     To be covered as emergency care, the condition must be one in which a prudent layperson, who has an average knowledge of
     medicine and health, could reasonably expect that without emergency care, the condition would:

     •   Place your health in serious jeopardy                          •    Cause serious disfigurement
     •   Cause serious problems with your body functions,               •    In the case of behavioral health, place others or
         organs or parts                                                     oneself in serious jeopardy
     Sometimes you have a need for medical care that is not an emergency (i.e., bronchitis, high fever, sprained ankle), but can’t
     wait for a regular appointment. If you need urgent care, call your physician or your physician’s backup. You can also call
     HealthLine at 1-877-TALK2RN (825-5276) for advice, 24 hours a day, seven days a week.
     Emergency Assistance 911
     In an emergency, call 911 for an ambulance or go directly to the nearest emergency room. If possible, go to the emergency
     room of a hospital in Empire’s network or the PPO network of another Blue Cross and/or Blue Shield plan.

     You pay only a co-payment for a visit to an emergency room. This co-payment is waived if you are admitted to the hospital
     within 24 hours. If you make an emergency visit to your doctor’s office, you pay the same co-payment as for an office visit.

     Benefits for treatment in a hospital emergency room are limited to the initial visit for an emergency condition. A participating
     provider must provide all follow-up care in order to receive maximum benefits.

     Remember: You will need to show your Empire BlueCross BlueShield I.D. card when you arrive at the emergency room.

     If you are admitted to the hospital, you or someone on your behalf must call Empire’s Medical Management Program before
     services are rendered or within 48 hours after you are admitted to or treated at the hospital, or as soon as reasonably possible. If
     you do not obtain authorization from Empire within the required time, a penalty of 50% of benefits will apply.

     Tips For Getting Emergency Care
         • If time permits, speak to your physician to direct you to the best place for treatment.
         • If you have an emergency while outside Empire’s service area anywhere in the United States, follow the same steps
            described on the previous page. If the hospital participates with another Blue Cross and/or Blue Shield plan in the
            BlueCard PPO program, your claim will be processed by the local plan. Be sure to show your Empire I.D. card at the
            emergency room, and if you are admitted, notify Empire’s Medical Management within 48 hours of admission. If the
            hospital does not participate in the BlueCard PPO program, you will need to file a claim.
         • If you have an emergency outside of the United States and visit a hospital which participates in the BlueCard
            Worldwide program, simply show your Empire I.D. card. The hospital will submit their bill through the BlueCard
            Worldwide Program. If the hospital does not participate with the BlueCard Worldwide program, you will need to file
            a claim.




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What’s Not Covered
These emergency services are not covered:
    • Use of the Emergency Room:
        − To treat routine ailments
        − Because you have no regular physician
        − Because it is late at night (and the need for treatment is not sudden and serious)
        − Ambulette
Air Ambulance
Air ambulance is provided to transport you to the nearest acute care hospital in connection with an emergency room or
emergency inpatient admission or emergency outpatient care when the following conditions are met:
     • Your medical condition requires immediate and rapid ambulance transportation and services cannot be provided by
          land ambulance due to great distances, and the use of land transportation would pose an immediate threat to your
          health.
     • Services are covered to transport you from one acute care hospital to another, only if the transferring hospital does not
          have adequate facilities to provide the medically necessary services needed for your treatment as determined by
          Empire, and use of land ambulance would pose an immediate threat to your health.
If Empire determines that the condition for coverage for air ambulance services have not been met but your condition did
require transportation by land ambulance to the nearest acute care hospital, Empire will only pay up to the amount that would
be paid for land ambulance to that hospital.

Benefits must be authorized by Empire’s Medical Management program before services are rendered, or within forty eight (48)
hours after a Covered Person is admitted to or treated at the hospital, or as soon as reasonably possible. Failure to obtain
authorization from Empire within the required time will result in a penalty of 50% of benefits otherwise available.

Remember to call Empire’s Medical Management Program at 1-800-982-8089 for prior authorization or within 48 hours after
services to receive benefits for air ambulance and to avoid the 50% penalty.
Land Ambulance
We will provide coverage for land ambulance transportation to the nearest acute care hospital, in connection with emergency
room care or emergency inpatient admission, provided by an ambulance service, when a prudent layperson, possessing an
average knowledge of medicine and health, could reasonably expect the absence of such transportation to result in
    •    placing the member’s health afflicted with a condition in serious jeopardy, or for behavioral condition, place the
         health of a member or others in serious jeopardy; or
    • serious impairment to a person’s bodily functions,
    • serious dysfunction of any bodily organ or part of a person; or
    • serious disfigurement to the member.
Benefits are not available for transfers of covered members between healthcare facilities.




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Maternity Care and Infertility Treatment
IF YOU ARE HAVING A BABY
     There are no out-of-pocket expenses after the initial office visit co-payment for maternity and newborn care when you use in-
     network providers. That means you do not need to continue to pay a co-payment when you visit the obstetrician. Furthermore,
     routine tests related to pregnancy, obstetrical care in the hospital or birthing center, as well as routine newborn nursery care are
     all covered 100% in-network.
     Whether services are provided in-network or out-of-network, call Empire’s Medical Management Program at 1-800-982-8089
     within the first three months of a pregnancy. This will ensure that you receive maximum benefits.
     Your baby is automatically covered under the plan for the first 30 days if you have family coverage. However, you will need to
     add the baby’s name as a covered dependent. If you do not have family coverage, call your employer within 30 days to add
     your newborn as a dependent.

MATERNITY CARE PROGRAM
     Empire understands that having a baby is an important and exciting time in your life so we developed the Maternity Care
     Program. Specially trained obstetrical nurses working with you and your doctor, help you and your baby obtain appropriate
     medical care throughout your pregnancy, delivery and after your baby’s birth. And just as important, we’re here to answer
     your questions.
     While most pregnancies end successfully with a healthy mother and baby, Maternity Care is also there to identify high-risk
     pregnancies. If necessary, Empire will suggest a network specialist to you who is trained to deal with complicated pregnancies.
     We can also provide home health care referrals and health education counseling.
     Please let us know as soon as you know that you’re pregnant, so that you will get the appropriate help. A complimentary book
     on prenatal care is waiting for you when you enroll in Maternity Care. Call 1-800-845-4742 and listen for the prompt that says
     “precertify.” You will be transferred to Empire’s Maternity Care Program.


                                     Obstetrical care in the hospital or an in-network birthing center is covered
        REMEMBER
                                 up to 48 hours after a normal vaginal birth and 96 hours after a Cesarean section.

     What’s Covered
     Covered services are listed in Your Benefits A t A Glance section. Following are additional covered services and limitations:
        • One home care visit fully covered by Empire if the mother leaves earlier than the 48-hour (or 96-hour) limit. The
             mother must request the visit from the hospital or a home health care agency within this timeframe (precertification is
             not required). The visit will take place within 24 hours after either the discharge or the time of the request, whichever
             is later.
        • Services of a certified nurse-midwife affiliated with a licensed facility. The nurse-midwife’s services must be
             provided under the direction of a physician.
        • Parent education, and assistance and training in breast or bottle feeding, if available
        • Circumcision of newborn males
        • Special care for the baby if the baby stays in the hospital longer than the mother. Call Empire’s Medical Management
             Program to precertify the hospital stay.
        • Semi-private room

     What’s Not Covered
     These maternity care services are not covered:
         • Days in hospital that are not medically necessary (beyond the 48-hour/96-hour limits)
         • Services that are not medically necessary
         • Private room
         • Out-of-network birthing center facilities
         • Private duty nursing

        REMEMBER                 Use a network obstetrician/gynecologist to receive the lowest cost maternity care.


     INFERTILITY TREATMENT
     Infertility as defined in regulations of the New York State Insurance Department means the inability of a couple to achieve a
     pregnancy after 12 months of unprotected intercourse as further defined in the regulations.



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What’s Covered
   Medical and surgical procedures, such as
   • Artificial insemination
   • Intrauterine insemination and
   • Dilation and curettage (D&C), including any required inpatient or outpatient hospital care, that would correct
       malformation, disease or dysfunction resulting in infertility; and services in relation to diagnostic tests and procedures
       necessary
   • To determine infertility, or
   • In connection with any surgical or medical procedures to diagnose or treat infertility. The diagnostic tests and
       procedures covered are:

            −   hysterosalpingogram                     −    testis biopsy
            −   hysteroscopy                            −    semen analysis
            −   endometrial biopsy                      −    blood tests
            −   laparoscopy                             −    ultrasound and
            −   sono-hysterorgram                       −    other medically necessary diagnostic tests and procedures, unless
            −   post-coital tests                            excluded by law.

Services must be medically necessary and must be received from eligible providers as determined by Empire in accordance
with applicable regulations of the New York State Insurance Department. In general, an eligible provider is defined as a
healthcare provider who meets the required training, experience and other standards established and adopted by the American
Society for Reproductive Medicine for the performance of procedures and treatments for the diagnosis and treatment
of infertility.
If you have prescription drug coverage, then prescription drugs approved by the FDA specifically for the diagnosis and
treatment of infertility that are not related to any excluded services are covered, subject to all the conditions, exclusions,
limitations and requirements that apply to all other prescription drugs under this plan.

What’s Not Covered
We will not cover any services related to or in connection with:
•   In-vitro fertilization                                          •    Cloning
•   Gamete intra-fallopian transfer (GIFT)                          •    Medical or surgical services or procedures that are
•   Zygote intra-fallopian transfer (ZIFT)                               experimental
•   Reversal of elective sterilizations, including vasectomies      •    Services to diagnose or treat infertility if we
    and tubal ligations                                                  determine, in our sole judgment, that the service
•   Sex-change procedures                                                was not medically necessary.

For members covered under this group plan, the new contract a member may convert to after termination of coverage may not
contain these infertility benefits.




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Hospital Services
IF YOU VISIT THE HOSPITAL
     Your plan covers most of the cost of your medically necessary care when you stay at a network hospital for surgery or
     treatment of illness or injury. No benefits are available when you use an out-of-network provider.
     You are also covered for same-day (outpatient or ambulatory) hospital services, such as chemotherapy, radiation therapy,
     cardiac rehabilitation and kidney dialysis. Same-day surgical services or invasive diagnostic procedures are covered when they:
          • Are performed in a same-day or hospital outpatient surgical facility
          • Require the use of both surgical operating and postoperative recovery rooms,
          • May require either local or general anesthesia,
          • Do not require inpatient hospital admission because it is not appropriate or medically necessary, and
          • Would justify an inpatient hospital admission in the absence of a same-day surgery program.
     Remember to call Empire’s Medical Management Program at 1-800-982-8089 at least two weeks prior to any planned surgery
     or hospital admission. For an emergency admission or emergency surgical procedure, call Medical Management within 48
     hours or as soon as reasonably possible. Otherwise your benefits may be reduced by 50% up to $5,000 for each hospital
     admission or surgery that is not precertified. Benefit reductions will also apply to all care related to the admission, including
     physician services.
     The medical necessity and length of any hospital stay are subject to Empire’s Medical Management Program guidelines. If
     Medical Management determines that the admission or surgery is not medically necessary, no benefits will be paid. See the
     Health Management section for additional information.
     If surgery is performed in a network hospital, you will receive in-network benefits for the anesthesiologist, whether or not the
     anesthesiologist is in the network.
     When you use a network hospital, you will not need to file a claim in most cases.

     Tips For Getting Hospital Care
         •    If your doctor prescribes pre-surgical testing (unlimited visits), have your tests done within seven days prior to
              surgery at the hospital where surgery will be performed. For pre-surgical testing to be covered, you need to have a
              reservation for both a hospital bed and an operating room.
         •    If you are having same-day surgery, often the hospital or outpatient facility requires that someone meet you after the
              surgery to take you home. Ask about their policy and make arrangements for transportation before you go in for
              surgery.
     Inpatient And Outpatient Hospital Care
     What’s Covered
     Covered services are listed in Your Benefits At A Glance section. Following are additional covered services and limitations for
     both inpatient and outpatient (same-day) care:
         • Diagnostic X-rays and lab tests, and other diagnostic tests such as EKG’s, EEG’s or endoscopies
         • Oxygen and other inhalation therapeutic services and supplies and anesthesia (including equipment for
              administration)
         • Anesthesiologist, including one consultation before surgery and services during and after surgery
         • Blood and blood derivatives for emergency care, same-day surgery, or medically necessary conditions, such as
              treatment for hemophilia
         • MRIs/MRAs, PET/CAT scans and nuclear cardiology services, when pre-approved by Empire’s Medical
              Management Program (your provider must call to precertify these services)
     Inpatient Hospital Care
     What’s Covered
     Following are additional covered services for inpatient care:
          • Semi-private room and board when
          − The patient is under the care of a physician, and           − A hospital stay is medically necessary.
          Coverage is for unlimited days, subject to Empire’s Medical Management Program review, unless otherwise specified
          • Operating and recovery rooms
          • Special diet and nutritional services while in the hospital
          • Cardiac care unit
          • Services of a licensed physician or surgeon employed by the hospital
          • Care related to surgery



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    •   Breast cancer surgery (lumpectomy, mastectomy), including:
    −   Reconstruction following surgery                             − Prostheses
    −   Surgery on the other breast to produce a                     − Treatment of physical complications at any stage of a
        symmetrical appearance                                            mastectomy, including lymphedemas
    The patient has the right to decide, in consultation with the physician, the length of hospital stay following
    mastectomy surgery.
    • Use of cardiographic equipment
    • Drugs, dressings and other medically necessary supplies
    • Social, psychological and pastoral services
    • Reconstructive surgery associated with injuries unrelated to cosmetic surgery
    • Reconstructive surgery for a functional defect which is present from birth
    • Physical, occupational, speech and vision therapy including facilities, services, supplies and equipment
    • Facilities, services, supplies and equipment related to medically necessary medical care
Outpatient Hospital Care
What’s Covered
Following are additional covered services for same-day care:
     • Same-day and hospital outpatient surgical facilities
     • Surgeons
     • Surgical assistant if:
        − None is available in the hospital or facility where the surgery is performed, and
        − The surgical assistant is not a hospital employee
     • Chemotherapy and radiation therapy, including medications, in a hospital outpatient department, doctor’s office or
        facility. Medications that are part of outpatient hospital treatment are covered if they are prescribed by the hospital
        and filled by the hospital pharmacy.
     • Kidney dialysis treatment (including hemodialysis and peritoneal dialysis) is covered in the following settings until
        the patient becomes eligible for end-stage renal disease dialysis benefits under Medicare:
        − At home, when provided, supervised and arranged by a physician and the patient has registered with an approved
             kidney disease treatment center (professional assistance to perform dialysis and any furniture, electrical,
             plumbing or other fixtures needed in the home to permit home dialysis treatment are not covered)
        − In a hospital-based or free-standing facility. See “hospital/facility” in the Definitions section.
Inpatient Hospital Care
What’s Not Covered
These inpatient services are not covered:
    • Private duty nursing
    • Private room. If you use a private room, you need to pay the difference between the cost for the private room and the
         hospital’s average charge for a semiprivate room.
    • Diagnostic inpatient stays, unless connected with specific symptoms that if not treated on an inpatient basis could
         result in serious bodily harm or risk to life
    • Services performed in the following:
    − Nursing or convalescent homes                                      − Spas
    − Institutions primarily for rest or for the aged                    − Sanitariums
    − Rehabilitation facilities (except for physical therapy)            − Infirmaries at schools, colleges or camps
    • Any part of a hospital stay that is primarily custodial
    • Elective cosmetic surgery or any related complications
    • Hospital services received in clinic settings that do not meet Empire’s definition of a hospital or other covered facility.
         See “hospital/facility” in the Details and Definitions section.
Outpatient Hospital Care
What’s Not Covered
These outpatient services are not covered:
    •    Same-day surgery not precertified as medically necessary by Empire’s Medical Management Program
    •    Routine medical care including but not limited to:
         − Inoculation or vaccination
         − Drug administration or injection, excluding chemotherapy
    •    Collection or storage of your own blood, blood products, semen or bone marrow



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Durable Medical Equipment and Supplies
IF YOU NEED EQUIPMENT OR MEDICAL SUPPLIES
     Your EPO covers the cost of medically necessary prosthetics, orthotics and durable medical equipment and medical supplies
     from network suppliers only. Out-of-network benefits are not available. Benefits and plan maximums are shown in Your
     Benefits At A Glance section.
     The network supplier must precertify the rental or purchase by calling Empire’s Medical Management Program at 1-800-982-
     8089. When using a supplier outside Empire’s operating area through the BlueCard PPO Program, you are responsible for
     precertifying services. An Empire network supplier may not bill you for covered services. If you receive a bill from one of
     these providers, contact Member Services at 1-800-767-8672.
     Coverage for enteral formulas or other dietary supplements for certain severe conditions is available. If you have prescription
     drug coverage with Empire Pharmacy ManagementSM, you may order these formulas or supplements through the Empire
     Pharmacy Management Program. Benefits and plan maximums are shown in Your Benefits At A Glance section.

     Tip For Obtaining Special Medical Supplies
     For prosthetics, orthotics and durable medical equipment, be sure the network vendor knows the number to call for Medical
     Management precertification.

     What’s Covered
     Covered services are listed in Your Benefits At A Glance section. Following are additional covered services and limitations:
        • Prosthetics, orthotics and durable medical equipment from network suppliers, when prescribed by a doctor and
             approved by Empire’s Medical Management Program, including:
             − Artificial arms, legs, eyes, ears, nose, larynx and external breast prostheses
             − Prescription lenses, if organic lens is lacking
             − Supportive devices essential to the use of an artificial limb
             − Corrective braces
             − Wheelchairs, hospital-type beds, oxygen equipment, sleep apnea monitors
        • Rental (or purchase when more economical) of medically necessary durable medical equipment
        • Replacement of covered medical equipment because of wear, damage or change in patient’s need, when ordered by
             a physician
        • Reasonable cost of repairs and maintenance for covered medical equipment
        • Disposable medical supplies such as syringes
        • Enteral formulas with a written order from a physician or other licensed health care provider. The order must
             state that:
             − The formula is medically necessary and effective, and
             − Without the formula, the patient would become malnourished, suffer from serious physical disorders or die.
        • Modified solid food products for the treatment of certain inherited diseases. A physician or other licensed healthcare
             provider must provide a written order.

     What’s Not Covered
     The following equipment is not covered:
     • Air conditioners or purifiers                                  •    Swimming pools
     • Humidifiers or dehumidifiers                                   •    False teeth
     • Exercise equipment                                             •    Hearing aids




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Skilled Nursing and Hospice Care
IF YOU NEED SKILLED NURSING OR HOSPICE CARE

   You receive coverage through Empire’s EPO for inpatient care in a skilled nursing facility or hospice. Benefits are available for
   network facilities only.
   In order to receive maximum benefits, please call 1-800-982-8089 to precertify skilled nursing and hospice care with Empire’s
   Medical Management Program.
   Skilled Nursing Care
   What’s Covered
   You are covered for inpatient care in a network skilled nursing facility if you need medical care, nursing care or rehabilitation
   services. The number of covered days is listed in Your Benefits At A Glance. Prior hospitalization is not required in order to be
   eligible for benefits. Services are covered if:
        • The doctor provides:
        − A referral and written treatment plan,                  − An explanation of the services the patient needs, and
       −    A projected length of stay,                            − The intended benefits of care.
       •    Care is under the direct supervision of a physician, registered nurse (RN), physical therapist, or other
            healthcare professional.
   What’s Not Covered
   The following skilled nursing care services are not covered:
   • Skilled nursing facility care that primarily:                 •    Convalescent care
       − Gives assistance with daily living activities             •    Sanitarium-type care
       − Is for rest or for the aged                               •    Rest cures
       − Treats drug addiction or alcoholism
   Hospice Care
   Empire covers up to 210 days of hospice care once in a covered person’s lifetime. Hospices provide medical and supportive
   care to patients who have been certified by their physician as having a life expectancy of six months or less. Hospice care can
   be provided in a hospice, in the hospice area of a network hospital, or at home, as long as it is provided by a network hospice
   agency.

   What’s Covered
   Covered services are listed in Your Benefits At A Glance section. Following are additional covered services and limitations:
      • Hospice care services, including:
           − Up to 12 hours of intermittent care each day by a registered nurse (RN) or licensed practical nurse (LPN)
           − Medical care given by the hospice doctor
           − Drugs and medications prescribed by the patient’s doctor that are not experimental and are approved for use by
                the most recent Physicians’ Desk Reference
           − Physical, occupational, speech and respiratory therapy when required for control of symptoms
           − Laboratory tests, X-rays, chemotherapy and radiation therapy
           − Social and counseling services for the patient’s family, including bereavement counseling visits until one year
                after death
           − Transportation between home and hospital or hospice when medically necessary
           − Medical supplies and rental of durable medical equipment
           − Up to 14 hours of respite care in any week




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     Tips for Receiving Skilled Nursing and Hospice Care
         •    To learn more about a skilled nursing facility, ask your doctor or caseworker to see the Health Facilities directory.
         •    Empire’s Medical Management Program will help direct you to a skilled nursing facility that provides the appropriate
              care. When selecting from among multiple facilities, you may want to consider:
              − Is the facility’s location convenient to friends, relatives and doctors?
              − What size facility is most suitable? A large facility may have more activities; a smaller one may be more
                   personal.
              − Are visiting hours convenient for friends and relatives?
              − Who directs your care? Does your doctor have privileges at the facility?
         •    For hospice care in your home, ask whether the same caregiver will come each day, or whether you will see someone
              new each time. What recourse do you have if you are not comfortable with the caregiver?


Home Health Care
IF YOU NEED HOME HEALTH CARE

     Home health care can be an alternative to an extended stay in a hospital or a stay in a skilled nursing facility. You receive
     coverage for home health care and home infusion therapy when you use an in-network provider. Benefits and plan maximums
     are shown in Your Benefits At A Glance section
     Remember, in order to receive maximum benefits, you need to precertify home health care through Empire’s Medical
     Management Program. If you use a home health care agency in Empire’s network, the agency must call Medical Management
     for precertification. If you use a home health care agency in the BlueCard PPO network, you need to call Medical
     Management. (The agency can call to precertify home health care for you, however, in order to receive maximum benefits, you
     need to ensure that they call.)
     Home infusion therapy, which is a service sometimes provided during home health care visits, is only available in-network. If
     you use an Empire network home infusion supplier, the supplier must call Medical Management for precertification. While a
     BlueCard PPO supplier can call to precertify your treatment, you need to ensure that they call.
     An Empire network home health care agency or home infusion supplier cannot bill you for covered services. If you receive a
     bill from one of these providers, contact Member Services at 1-800-767-8672.
     What’s Covered
     Covered services are listed in Your Benefits At A Glance section. Following are additional covered services and limitations:
        • Up to 200 precertified home health care visits per year. A visit is defined as up to four hours of care. Care can be
             given for up to 12 hours a day (three visits). Your physician must certify home health care as medically necessary and
             approve a written treatment plan.
        • Home health care services include:
             − Part-time services by a registered nurse (RN) or licensed practical nurse (LPN)
             − Part-time home health aide services (skilled nursing care)
             − Physical, speech or occupational therapy, if restorative
             − Medications, medical equipment and supplies prescribed by a doctor
             − Laboratory tests

     What’s Not Covered
     The following home health care services are not covered:
         • Custodial services, including bathing, feeding, changing or other services that do not require skilled care
         • Out-of-network home infusion therapy




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Physical, Occupational, Speech or Vision Therapy
IF YOU NEED THERAPY
   You receive benefits through Empire’s EPO for outpatient physical, occupational, speech and vision therapy by a network
   provider. There are no benefits for out-of-network services.
   Please call Empire’s Medical Management Program at 1-800-982-8089 to precertify all physical, occupational, and speech
   therapy. This will ensure that you receive maximum benefits.

   Tip for Receiving Therapy
       • Ask for exercises you can do at home that will help you get better faster.
   What’s Covered
   Covered services are listed in Your Benefits At A Glance section. Following are additional covered services and limitations:
      • Physical therapy, physical medicine or rehabilitation services, or any combination of these on an inpatient or
           outpatient basis up to the plan maximums if:
           − Prescribed by a physician,
           − Designed to improve or restore physical functioning within a reasonable period of time, and
           − Approved by Empire’s Medical Management Program.

   Outpatient care must be given at home, in a therapist’s office or in an outpatient facility by an in-network provider; inpatient
   therapy must be short-term.
        • Occupational, speech or vision therapy, or any combination of these on an outpatient basis up to the plan maximums
            if:
            − Prescribed by a physician or in conjunction with a physician’s services,
            − Given by skilled medical personnel at home, in a therapist’s office or in an outpatient facility,
            − Performed by a licensed speech/language pathologist or audiologist, and
            − Approved by Empire’s Medical Management Program, except vision therapy.


   What’s Not Covered
   The following therapy services are not covered:
       • Therapy to maintain or prevent deterioration of the patient’s current physical abilities
       • Tests, evaluations or diagnoses received within the 12 months prior to the doctor’s referral or order for occupational,
            speech or vision therapy




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Behavioral Healthcare
IF YOU NEED BEHAVIORAL HEALTHCARE

     At Empire we realize that your mental health is as important as your physical health. That’s why we include behavioral health
     benefits at little out-of-pocket cost. Your behavioral healthcare benefits cover outpatient treatment for alcohol or substance
     abuse, inpatient detoxification inpatient alcohol and substance abuse rehabilitation and inpatient and outpatient mental health
     care from network providers only. You will not receive benefits for any of these services if you go out-of-network.
     To help ensure that you receive appropriate care, you need to precertify all behavioral healthcare services in advance. When
     you call the Behavioral Healthcare Management Program at 1-800-626-3643 to precertify in-network services, a counselor will
     refer you to an appropriate hospital, facility or provider and send written confirmation of the authorized services.
     If you do not call to precertify behavioral healthcare, or if you call but do not follow their recommended treatment plan,
     covered benefits may be denied or reduced as follows:
          • 50% up to $5,000 per inpatient admission for mental health or alcohol/substance abuse detoxification
          • 50% for each outpatient mental health visit
          • 50% for each outpatient alcohol and substance abuse facility or provider visit
          • 50% for each professional mental health care visit made during an inpatient stay

                         When you are admitted in an emergency to a hospital or other inpatient facility for behavioral
                            health problems, you or someone on your behalf must call the Behavioral Healthcare
                         Management Program at 1-800-626-3643 within 48 hours or as soon as is reasonably possible.

        REMEMBER                      If you want to know if a provider or facility is covered in-network, call the
                                                    Behavioral Healthcare Management Program.

                                If you do not agree with a certification decision made by the Behavioral Healthcare
                                      Management Program, you can file an appeal. For more information see
                                         “Appeals and Grievances” in the Details and Definitions section.



     Mental Health Care
     What’s Covered
     Covered services are listed in Your Benefits At A Glance section. Following are additional covered services and limitations:
        • Electroconvulsive therapy for treatment of mental or behavioral disorders, if precertified by Behavioral Healthcare
             Management
        • Care from psychiatrists, psychologists or licensed clinical social workers, providing psychiatric or psychological
             services within the scope of their practice, including the diagnosis and treatment of mental and behavioral disorders.
             Social workers must be licensed by the New York State Education Department or a comparable organization in
             another state, and have three years of post-degree supervised experience in psychotherapy and an additional three
             years of post-licensure supervised experience in psychotherapy.
         •    Treatment in a comprehensive care center for eating disorders.


     Treatment for Alcohol or Substance Abuse
     What’s Covered
        In addition to the services listed in Your Benefits At A Glance section, the following services are covered:
         •    Family counseling services for alcohol or substance abuse at an outpatient treatment facility. These can take place
              before the patient’s treatment begins. Any family member covered by the plan may receive one counseling visit per
              day.
              − Visits for family counseling are deducted from the 60 visits available for outpatient treatment.
     What’s Not Covered
     The following alcohol and substance abuse treatment services are not covered:
         •    Care that is not medically necessary




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                                                                    SM
Empire Pharmacy Management
YOUR PHARMACY BENEFITS PROGRAM
   Empire understands that filling prescriptions can be costly. To help reduce your costs, Empire offers the Pharmacy
   Management program. Your Empire pharmacy benefits program covers most drugs, as long as they have been prescribed by a
   physician and approved by the Federal Drug Administration (FDA).

FILLING A PRESCRIPTION
   You pay a co-payment and/or a deductible each time you fill your prescription at a network pharmacy. Co-payments vary
   depending on whether the prescription is for a generic, brand-name formulary or non-formulary drug. Using generic
   medicines, where appropriate, will help you to maximize your benefits.

EMPIRE’S DRUG FORMULARY
   Empire’s Drug Formulary is a list of covered prescription drugs recommended for use by Empire’s providers. It includes
   generic and certain covered brand-name drugs. You will pay a higher co-payment for brand-name formulary and non-
   formulary drugs, and realize the most savings for generic drugs.
   You can get an up-to-date formulary by visiting www.empireblue.com/nyc or calling Member Services 1-800-767-8672
   Member Services can also provide information about Empire’s procedures and pharmaceutical decisions.
   Certain drugs require prior authorization. They are identified as “PAR” (Prior Authorization Required) and must be approved
   by Empire before you fill the prescription. Your physician or pharmacist can request this authorization by calling Empire
   Pharmacy Services at 1-800-767-8672. Some drugs have quantity limits. They are indicated by the letters “QL” (Quantity
   Limit) and require authorization only if a prescription is written for more than the monthly allowed amount. The drugs
   requiring any of these actions are noted on the formulary list. If the quantity is approved, it will be covered.
   Some drugs must be specially ordered. In order for certain specialty injectable medications to be covered under Empire’s
   pharmacy plan, prescriptions must be filled by Caremark (formerly known as AdvancePCS) SpecialtyRx. Those particular
   medications are listed with the symbol SRx next to them. For further information regarding filling a prescription for specialty
   injectable medications with Caremark Specialty Rx, call 1-866-295-2779, Monday – Friday, 8:00 a.m. to 6:00 p.m. EST.
   The formulary and procedures are made available to all network providers at least once a year, or sooner if there are changes.

                             Benefits are only available for prescriptions filled at network pharmacies or through
      REMEMBER
                                                          Empire’s mail-order program.



NETWORK PHARMACY
   You must fill a prescription at an Empire network pharmacy for up to a 30-day supply of FDA-approved drugs, if prescribed
   by a physician or other licensed provider. Empire Pharmacy Management offers:
        • Low cost. You can receive up to a 30-day supply for each drug for a single co-payment.
        • Convenience. You must present your Empire ID card to the pharmacist along with your prescription. That’s all you
            need to get the cost advantages of this program.
        • No claim forms! Under your policy guidelines, paper claims cannot be submitted. The pharmacist must submit your
            claim when you fill the prescription.

   Tips for Using Mail Order
   The first time you fill a prescription through mail order, ask your physician for a second prescription for a three-week supply.
   You can fill the second prescription at a local pharmacy so you have the medication until the mail order is processed.

                                                A pharmacist is not required to fill a prescription that
      REMEMBER
                                           in the pharmacist’s professional judgment should not be filled.

   How to Order Your Prescription by Mail
      • The first time you fill a prescription through mail order, ask your physician for a second prescription for a three-week
          supply. You can fill the second prescription at a local pharmacy so you have the medication until the mail order is
          processed.
      • Complete the mail order form you received in the mail with your ID card(s). You can get additional forms by going
          to www.empireblue.com/nyc or calling Empire Pharmacy Management at the number on the back of your member ID
          card.
      • Place your order for a refill at least three weeks before your current supply will run out.


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     You will receive your filled prescription at your home within 14 working days, postage paid. If you prefer, you can also choose
     faster shipping for an additional fee.
MANAGE YOUR PHARMACY PLAN ONLINE
     Taking care of your pharmacy needs is easier than ever with Empire’s online pharmacy. If you’re registered for Online
     Member Services, just go to www.empireblue.com/nyc where you can:
         • Search Empire’s drug formulary for a particular drug (by name or therapeutic category)
         • Locate a participating retail pharmacy near where you live or work
         • Order prescription refills through the mail order program
         • Research usage instructions, drug interactions and side effects for thousands of medications
     Simply log on to our web site and access your own personal secure home page. Click on “My Pharmacy Plan” which is right
     next to the Rx symbol under “Your Health Plan.” You’ll immediately be connected to Caremark.com. It’s like having a
     pharmacy right in your own home.
                     Empire Pharmacy Management Customer Service: 1-800-767-8672
     What’s Covered
     The following prescription drugs are covered:
     • Insulin and self-administered injectables                   •    Infertility drugs
     • Diabetic supplies and equipment                             •    Contraceptive drugs or devices
     • Enteral formulas for home use that are medically            •    Bone mineral density drugs and devices
         necessary and proven effective for the specific           •    Refills for up to one year from the date of the original
         disease when prescribed by a written order by a                prescription, if authorized by the physician and indicated
         physician or other health care provider licensed to            on the prescription
         prescribe under applicable law
     • Nutritional supplements when medically
         necessary and proven effective for treatment
     What’s Not Covered
     The following items are not covered:
         • Drugs or devices that do not require a prescription or are available over the counter, except insulin and diabetic
              supplies
         • Devices of any type, such as therapeutic devices, IUD’s, artificial appliances, hypodermic needles, syringes or similar
              devices, except where specifically covered, and except for bone density testing and treatment devices
         • Charges or fees for drug administration or injection
         • Vitamins that by law do not require a prescription
         • Drugs received while in a hospital, nursing home or other facility (covered under medical plan as indicated)
         • Investigational or experimental drugs (i.e., medications used for experiments and/or dosage levels determined by
              Empire to be experimental) Refer to the Exclusions and Limitations Section and also the Complaints, Appeals and
              Grievances Section.
         • Appetite suppressants, unless medically necessary
         • Compounded medications with no ingredients that require a prescription
         • Medications for cosmetic purposes only
         • Medications not approved by the FDA, unless otherwise required by law (i.e., drugs that have been prescribed for the
              treatment of a type of cancer for which the drug has not been approved by the FDA and not considered investigational
              or experimental)
         • Replacement of lost, stolen or damaged prescription medications
         • The cost for medication in excess of plan limits
         • Smoking cessation products, unless medically necessary
         • Refills not dispensed in accordance with the prescription
         • Refills beyond one year from the original prescription date




26                                                    www.empireblue.com
Exclusions and Limitations
EXCLUSIONS
    In addition to services mentioned under “What’s Not Covered” in the prior sections, your plan does not cover the following:

    Dental Services
       • Dental services, including but not limited to:
       − Cavities and extractions                                       −    False teeth
       − Care of gums                                                   −    Treatment of TMJ that is dental in nature
       − Bones supporting the teeth or periodontal abscess              −    Orthognathic surgery that is dental in nature
       − Orthodontia
    However, your plan does cover:
         •    Surgical removal of impacted teeth
         •    Treatment of sound natural teeth injured by accident if treated within 12 months of the injury

    Experimental/Investigational Treatments
         •    Technology, treatments, procedures, drugs, biological products or medical devices that in Empire’s judgment are:
         −    Experimental or investigative                               − Obsolete or ineffective
         •    Any hospitalization in connection with experimental or investigational treatments. “Experimental” or “investigative”
              means that for the particular diagnosis or treatment of the covered person’s condition, the treatment is:
              − Not of proven benefit
              − Not generally recognized by the medical community (as reflected in published medical literature)
    Government approval of a specific technology or treatment does not necessarily prove that it is appropriate or effective for a
    particular diagnosis or treatment of a covered person’s condition. Empire may require that any or all of the following criteria be
    met to determine whether a technology, treatment, procedure, biological product, medical device or drug is experimental,
    investigative, obsolete or ineffective:
         •     There is final market approval by the U.S. Food and Drug Administration (FDA) for the patient’s particular diagnosis
               or condition, except for certain drugs prescribed for the treatment of cancer. Once the FDA approves use of a medical
               device, drug or biological product for a particular diagnosis or condition, use for another diagnosis or condition may
               require that additional criteria be met.
          • Published peer-review medical literature must conclude that the technology has a definite positive effect on
               health outcomes
          • Published evidence must show that over time the treatment improves health outcomes (i.e., the beneficial effects
               outweigh any harmful effects)
          • Published proof must show that the treatment at the least improves health outcomes or that it can be used in
               appropriate medical situations where the established treatment cannot be used. Published proof must show that the
               treatment improves health outcomes in standard medical practice, not just in an experimental laboratory setting.
However, your plan will cover an experimental or investigational treatment approved by an External Appeal agent certified by the
state. Refer to the Complaints, Appeals and Grievances Section.
    Government Services
       • Services covered under government programs, except Medicaid or where otherwise noted
       • Government hospital services, except:
          − Specific services covered in a special agreement between Empire and a government hospital
          − United States Veterans’ Administration or Department of Defense Hospitals, except services in connection with
             a service-related disability. In an emergency, Empire will provide benefits until the government hospital can
             safely transfer the patient to a participating hospital.
    Home Care
       • Services performed at home, except for those services specifically noted elsewhere in this Guide as available either at
          home or as an emergency.
    Inappropriate Billing
        • Services usually given without charge, even if charges are billed
        • Services performed by hospital or institutional staff which are billed separately from other hospital or institutional
           services, except as specified



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     Medically Unnecessary Services
        • Services, treatment or supplies not medically necessary in Empire’s judgment. See Definitions section for more
            information.
     Miscellaneous
        • Surgery and/or treatment for gender change

     Prescription Drugs
        • All over the counter drugs, vitamins, appetite suppressants, or any other type of medication, unless specifically
             indicated.

     Sterilization/Reproductive Technologies
         • Reversal of sterilization
         • Assisted reproductive technologies including but not limited to
         − In-vitro fertilization                                    − Gamete and zygote intrafallopian tube transfer
                                                                     − Intracytoplasmic sperm injection
     Travel
         • Travel, even if associated with treatment and recommended by a doctor

     Vision Care
         • Eyeglasses, contact lenses and the examination for their fitting except following cataract surgery, unless
             specifically indicated

     War
        •     Services for illness or injury received as a result of war

     Workers’ Compensation
        • Services covered under Workers’ Compensation, no-fault automobile insurance and/or services covered by similar
            statutory programs

LIMITATION AS INDEPENDENT CONTRACTOR
     The relationship between Empire and hospitals, facilities or providers is that of independent contractors. Nothing in this
     contract shall be deemed to create between Empire and any hospital, facility or provider (or agent or employee thereof) the
     relationship of employer and employee or of principal and agent. Empire BlueCross BlueShield will not be liable in any
     lawsuit, claim or demand for damages incurred or injuries that you may sustain resulting from care received either in a
     hospital/facility or from a provider.




28                                                      www.empireblue.com
Health Management
HELPING YOU MANAGE YOUR HEALTH

   Managing your health includes getting the information you need to make informed decisions, and making sure you get the
   maximum benefits the plan will pay. To help you manage your health, Empire provides three important services: Medical
   Management, Case Management and HealthLine SM Nurse Access.


Empire’s Medical Management Program
   Empire’s Medical Management Program is a service that precertifies hospital admissions and certain treatments and procedures
   to ensure that you receive high quality care for the right length of time, in the right setting, with maximum coverage.

   When you call Empire’s Medical Management Program, you reach a team of professionals who know how to help you manage
   your benefits to your best advantage. They can help you to:

       • Learn more about your healthcare options
       • Choose the most appropriate healthcare setting or service (e.g., hospital or same-day surgery unit)
       • Avoid unnecessary hospitalization and the associated risks, whenever possible
       • Arrange for any required (and covered) discharge services
   To help ensure that you receive quality care, Empire’s Medical Management Program works with you and your provider to:
       •    Review planned and emergency hospital admissions
       •    Review ongoing hospitalization
       •    Review inpatient and same-day surgery
       •    Review high risk pregnancies
       •    Review routine maternity admissions
       •    Perform individual case management
       •    Review care in a hospice or skilled nursing facility
       •    Review home health care and home infusion therapy
       •    Coordinate discharge planning
   In most situations, you or someone acting on your behalf needs to call the Medical Management Program to precertify hospital
   admissions and certain services. In other cases, the vendor or provider of services needs to call. This will ensure you receive
   maximum benefits.

   The following chart shows which healthcare services must be precertified with Empire’s Medical Management Program before
   you receive them.




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                                CALL TO PRECERTIFY …                                                        HOW COVERED                   WHO CALLS TO PRECERTIFY

          ALL HOSPITAL ADMISSIONS
          •      At least two weeks prior to any planned surgery or
                 hospital admission                                                                          Empire and
                                                                                                                                                           YOU
          •      Within 48 hours of an emergency hospital admission,                                    BlueCard PPO network
                 or as soon as reasonably possible
          •      For illness or injury to newborns

          PREGNANCY                                                                                          Empire and
                                                                                                                                                           YOU
          •      Within the first three months of a pregnancy                                           BlueCard PPO network


          BEFORE YOU RECEIVE
          •      Inpatient physical therapy
          •      Same-day surgery for medically necessary cosmetic/
                 reconstructive surgery, outpatient transplants and
                 ophthalmological or eye-related procedures
          •      Cardiac rehabilitation                                                                      Empire and
                                                                                                                                                           YOU
                                                                                                        BlueCard PPO network
          •      Hospice care
          •      Occupational or speech therapy
          •      Outpatient physical therapy
          •      Skilled nursing facility care
          •      Air ambulance service


          BEFORE YOU RECEIVE                                                                                 Empire network                    NETWORK SUPPLIER

          •      Home health care services                                                             BlueCard PPO network                                YOU

          BEFORE YOU
                                                                                                             Empire network                    NETWORK SUPPLIER
          •      Receive home infusion therapy
          •      Rent, purchase or replace prosthetics, orthotics or
                                                                                                       BlueCard PPO network                                YOU
                 durable medical equipment

          BEFORE YOU RECEIVE
                                                                                                             Empire network                            PROVIDER
          •      Chiropractic care*
          •      MRIs/MRAs**
          •      Nuclear cardiology services **
                                                                                                       BlueCard PPO network                            PROVIDER
          •      PET/CAT scans**




     It is the provider’s responsibility to call Empire for precertification of all in-network chiropractic care after the fifth visit.
*
     It is the provider’s responsibility to call Empire for precertification of all in-network PET/ CAT scans, MRIs/ MRAs and Nuclear Cardiology services. Penalties will apply if
**
     precertification is not obtained.




30                                                                               www.empireblue.com
                                      When you call the Medical Management Program to precertify services,
       REMEMBER
                                      you receive maximum benefits and helpful advice about your options


IF SERVICES ARE NOT PRECERTIFIED
    If you call to precertify services as needed, you will receive maximum benefits. Otherwise, benefits may be reduced by 50%
    up to $5,000 for each admission, treatment or procedure. This benefit reduction also applies to certain same-day surgery and
    professional services rendered during an inpatient admission. If the admission or procedure is not medically necessary, no
    benefits will be paid.

    Tips for Precertifying Services with Medical Management
         •   Have the following information about the patient ready when you call:
             − Name, birth date and sex
             − Address and telephone number
             − Empire I.D. card number
             − Name and address of the hospital/facility
             − Name and telephone number of the admitting doctor
             − Reason for admission and nature of the services to be performed
         •   When the vendor or provider is required to call Empire’s Medical Management Program for precertification, be sure
             they know about the precertification requirement and that they have the Medical Management telephone number.

    Initial Decisions
    Empire will comply with the following timeframes in processing precertification, concurrent and retrospective review of
    requests for services.
         • Precertification Requests. Precertification means that you must contact Empire’s Medical Management Program for
              approval before you receive certain health care services. We will review all requests for precertification within three
              (3) business days of receipt of the necessary information but not to exceed 15 calendar days from the receipt of the
              request. If we do not have enough information to make a decision within three (3) business days, we will notify you in
              writing of the additional information we need, and you and your provider will have 45 calendar days to respond. We
              will make a decision within three (3) business days of our receipt of the requested information, or if no response is
              received, within three (3) business days after the deadline for a response.
         • Urgent Precertification Requests. If the need for the service is urgent, we will render a decision as soon as possible,
              taking into account the medical circumstances, but in any event within 72 hours of our receipt of the request. If the
              request is urgent and we require further information to make our decision we will notify you within 24 hours of
              receipt of the request and you and your provider will have 48 hours to respond. We will make a decision within 48
              hours of our receipt of the requested information, of if no response is received, within 48 hours after the deadline for a
              response.
         • Concurrent Requests. Concurrent review means that Empire reviews your care during your treatment to be sure you
              get the right care in the right setting and for the right length of time. We will complete all concurrent reviews of
              services within 24 hours of our receipt of the request.
         • Retrospective Requests. Retrospective review is conducted after you receive medical services. We will complete all
              retrospective reviews of services already provided within 30 calendar days of our receipt of the claim. If we do not
              have enough information to make a decision within 30 calendar days, we will notify you in writing of the additional
              information we need, and you and your provider will have 45 calendar days to respond. We will make a decision
              within 15 calendar days of our receipt of the requested information, or if no response is received, within 15 calendar
              days after the deadline for a response.
If Empire’s Medical Management Program does not meet the above time frames, the failure should be considered a denial. You or
your doctor may immediately appeal.

IF A REQUEST IS DENIED
    All denials of benefits will be rendered by qualified medical personnel. If a request for care or services is denied for lack of
    medical necessity, or because the service has been determined to be experimental or investigational, Empire’s Medical
    Management Program will send a notice to you and your doctor with the reasons for the denial. You will have the right to
    appeal. See section in this booklet titled “Complaints, Appeals and Grievances” for more information.
    If Empire’s Medical Management Program denies benefits for care or services without discussing the decision with your
    doctor, your doctor is entitled to ask Medical Management to reconsider their decision. A response will be provided by
    telephone and in writing within one business day of making the decision.



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New Medical Technology
REQUESTING COVERAGE
     Empire uses a committee composed of Empire Medical Directors, who are doctors, and participating network physicians, to
     continuously evaluate new medical technology that has not yet been designated as a covered service. If you want to request
     certification of a new medical technology before beginning treatment, your provider must contact Empire’s Medical
     Management Program. The provider will be asked to do the following.
          • Provide full supporting documentation about the new medical technology
          • Explain how standard medical treatment has been ineffective or would be medically inappropriate
          • Send us scientific peer reviewed literature that supports the effectiveness of this particular technology. The literature
                must not be in the form of an abstract or individual case study.
     Empire’s staff will evaluate the proposal in light of your contract and Empire’s current medical policy. Empire will then review
     the proposal, taking into account relevant medical literature, including current peer review articles and reviews. Empire may
     use outside consultants, if necessary. If the request is complicated, Empire may refer your proposal to a multi-specialty team of
     physicians or to a national ombudsman program designed to review such proposals. Empire will send all decisions to the
     member and/or provider.



Case Management
IF YOU NEED ADDITIONAL SUPPORT FOR SERIOUS ILLNESS
     The Medical Management Program’s Case Management staff can provide assistance and support when you or a member of
     your family faces a chronic or catastrophic illness or injury. Empire's nurses can help you and your family:
          • Find appropriate, cost-effective healthcare options
          • Reduce medical cost
          • Assure quality medical care
     A Case Manager serves as a single source for patient, provider, and insurer – assuring that the treatment, level of care, and
     facility are appropriate for your needs. For example, Case Management can help with cases such as:

     •   Cancer                                     •   Chronic illness
     •   Stroke                                     •   Hemophilia
     •   AIDS                                       •   Spinal cord and other traumatic injuries
     Assistance from Case Management is evaluated and provided on a case by case basis. In some situations, Empire’s Medical
     Management Program staff will initiate a review of a patient's health status and the attending doctor's plan of care. They may
     determine that a level of benefits not necessarily provided by the EPO is desirable, appropriate and cost-effective. If you would
     like Case Management assistance following an illness or surgery, contact Empire’s Medical Management Program at 1-800-
     982-8089.




32                                                      www.empireblue.com
Healthy Living Programs
PREVENTIVE CARE
   Preventive care is an important and valuable part of your healthcare. Regular physical check-ups and appropriate screenings
   can help you and your doctor detect illness early. When you treat an illness or condition early, you minimize the risk of a
   serious health problem and reduce the risk of incurring greater costs. That’s why Empire provides many preventive care
   services for free or only a small co-payment when you use network providers. No benefits are available when you use an out-
   of-network provider.
   For more information on staying healthy, be sure to check the My Health section of www.empireblue.com/nyc There you’ll find the
   latest information on hundreds of topics ranging from nutrition to stress management to children’s immunization guidelines.

   Tips For Using Preventive Care
       • Visit your doctor once a year for a check-up. Take the screening tests appropriate for your gender and age to help
          identify illness or the risk of serious illness.
       • Women with no prior or family history of breast cancer, get a baseline mammogram between ages 35-39, and for
          ages 40 and over an annual mammogram. Women who have a family history of breast cancer will be covered for a
          routine mammogram at any age and as often as their physician recommends one.
       • Keep your children healthy by getting routine check-ups and preventive care, including certain immunizations.

   What’s Covered
   Covered services are listed in Your Benefits At A Glance section. Following are additional covered services and limitations:
      • Well-woman care visits to a gynecologist/obstetrician
      • Bone Density Testing and Treatment. Standards for determining appropriate coverage include the criteria of the
           federal Medicare program and the criteria of the National Institutes of Health for the Detection of Osteoporosis. Bone
           mineral density measurements or tests, drugs and devices include those covered under Medicare and in accordance
           with the criteria of the National Institutes of Health, including, as consistent with such criteria, dual energy X-ray
           absorptiometry.
      • Coverage shall be available for individuals meeting the criteria of those programs, including one or more of the
           following:
           − Previously diagnosed with or having a family history of osteoporosis
           − Symptoms or conditions indicative of the presence or significant risk of osteoporosis
           − Prescribed drug regimen posing a significant risk of osteoporosis
           − Lifestyle factors to such a degree posing a significant risk of osteoporosis
           − Age, gender and/or other physiological characteristics that pose a significant risk of osteoporosis.
      • Well-child care visits to a pediatrician, nurse or licensed nurse practitioner, including a physical examination, medical
           history, developmental assessment, guidance on normal childhood development and laboratory tests. The tests may
           be performed in the office or a laboratory. The number of visits covered per year depends on your child’s age.
      • Well-child care immunizations as listed:

              −   DPT (diphtheria, pertussis and tetanus)               −   Tetanus-diphtheria
              −   Polio                                                 −   Pneumococcal
              −   MMR (measles, mumps and rubella)                      −   Meningococcal Tetramune
              −   Varicella (chicken pox)                               −   Other immunizations as determined by the
              −   Hepatitis B                                               Superintendent of Insurance and the Commissioner of
              −   Hemophilus                                                Health in New York State or the state where your child
                                                                            lives

   What’s Not Covered
   These preventive care services are not covered:
       • Screening tests done at your place of work at no cost to you
       • Free screening services offered by a government health department
       • Tests done by a mobile screening unit, unless a doctor not affiliated with the mobile unit prescribes the tests




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360° HealthSM – Empire’s Health Services Programs
EMPIRE’S HEALTH SERVICES PROGRAM, 360º HEALTHSM, HELPS YOU IMPROVE, MANAGE
AND MAINTAIN YOUR HEALTH.

No matter what your healthcare needs, as an Empire plan member you have access to programs and services to help you achieve
and maintain your highest potential for good health —at no additional charge. 360º Health is a group of programs that surround you
with personalized support. From preventive care to managing complex conditions, we are there when you need us.
Empire’s 360° Health is organized into:
         • Online health and wellness resources.
         • Discounts on health-related products and alternative therapies
         • Guidance and support for when you need help
         • Condition management for those with chronic health issues.
The following are descriptions of some of the programs and services available to you:
HealthLine SM Nurse Access and Recorded Topics – receive immediate assistance from a registered nurse, toll-free, 24-hours, 7-
days-a-week. Simply call 1-877-Talk-2-RN (1-877-825-5276). If you need advice on comforting a baby in the middle of the night
or need to locate a doctor, we’ll be there. Call us to:
          • Assess and understand your symptoms.
          • Find additional help to make informed healthcare decisions.
          • Locate a doctor, hospital or other practitioner.
          • Get information about an illness, medication or prescription.
          • Find information about a personal health issue such as diet, exercise or high blood pressure
          • Answer questions on pregnancy
          • Get assistance with discharge from a hospital
          • Help you decide if a medical situation requires emergency treatment.
You can also access an easy-to-use audio library. You’ll hear advice and news delivered in English and Spanish on more than 1,100
topics ⎯ from colds and sore throats to diabetes and cancer. Please refer to the back of this book for a list of recorded topics.
HealthLine is not for emergencies, so please do not call if you believe you or a family member
        • Is having a heart attack or stroke
        • Is severely injured
        • Is unable to breathe
        • May have ingested poisonous or toxic substances
        • Is unconscious.
In these cases, call 911 or your local emergency service as soon as possible.
Here’s how to use HealthLine:
         • Dial 1-877-Talk-2-RN (1-877-825-5276) and follow the prompts to speak with a nurse or listen to the audiotape
              messages.
         • If you plan on listening to the tapes, have your member ID number handy. You will need to enter the first three digits.
              For example, if your number is YLD123456789, enter YLD (123). For members who don’t speak English, stay on
              the line to be connected to an interpreter.
         • The back of this book contains a complete listing of audiotape messages. Note the code number to the right of the
              topic(s) that you want to listen to, as you will be prompted for the number.
         • If you have additional questions after listening to a tape, simply connect to the on-duty nurse.
Empire Healthy Discounts – Members can receive discounts on alternative medicine therapies and other health services. Go to the
“Members” section of www.empireblue.com/nyc, look under “Empire’s Plans” and click on your plan name. You can get access to
discounts, services and products such as:
         Alternative Practitioners – Receive discounts on services from hundreds of chiropractors, acupuncturists, massage
         therapists and nutritional counselors participating in alternative healthcare programs administered by American Specialty
         Health NetworksTM (ASH Networks) — all without a doctor’s referral. Search ASH Network’s online directory at
         www.healthyroads.com and show your member ID at your office visit to quality for the discount.

         Wellness Products – Members receive discounts of up to 40% on thousands of quality health and wellness products:
         vitamins, herbal supplements, homeopathic remedies, sports nutrition products, health-related books and videos and more.
         You may purchase products by visiting www.healthyroads.com or by calling 1-888-289-4325.




34                                                    www.empireblue.com
         Vision Services – Save up to 25% on laser vision correction, as well as up to 75% on vision care with Davis Vision,
         including complete eye exams, lenses, frames, and mail-order contact lens replacement. You can locate a network
         provider at www.davisvision.com or call 1-877-92-DAVIS (1-877-923-2847). Simply present your Empire member ID at
         the time of your appointment. Discounted vision services are available only to Empire members who are not covered by a
         Davis Vision care benefits rider to their health plan. If you are covered by a Davis Vision care benefits rider, then many of
         these discounts are actively covered benefits under your plan. Call the number on the back of your member ID card to
         verify your vision coverage.
         Fitness Club Membership – Save on membership fees and receive a free one-week membership with any of the thousands
         of facilities in the International Fitness Club Network (IFCN). You can even get discounts on home fitness equipment. To
         find a club near you and printout savings certificates, visit www.ifcn.org or call 1-800-866-8466.
         Weight Loss Programs – Get free registration at your participating local New York or New Jersey Weight Watchers®1
         location. Just show your Empire member ID card upon registering. For more information or to find a location near you,
         visit www.weightwatchers.com or call 1-800-651-6000.

Please note that these services and products may not be available to your group and in all states, and are not covered benefits
under your Empire healthcare plan. Empire makes no payment for these value-added programs available to you. Members pay the
full amount of the provider’s discounted fee.
Empire does not endorse or warrant these discounted services and products in any way. Empire reserves the right to change,
amend or withdraw any and all discount programs or services at any time without notice to any party.

Member Newsletter – Our semi-annual member newsletter, Healthy Living, contains a variety of articles on staying healthy and
coping with chronic diseases such as diabetes and asthma as well as helpful information about your health plan.
Preventive Healthcare Guides – Distributed both in our member newsletter and available online at www.empireblue.com/nyc, these
guides can help you and your family stay up-to-date on check-ups, immunizations, screenings and tests throughout every stage of
your life.
My Health, powered by WebMD – this vast one-stop resource center of health information, services and tools is accessible to all
eligible members through Member Online Services at www.empireblue.com/nyc.You’ll be able to find out if you are at risk for
certain conditions, access the latest in health news, learn about treatments for common conditions and diseases, and much more.
You’ll also find preventative healthcare guidelines including the important tests to take and discuss with your doctor. Topics include
an online fitness program, LEAP (Lifetime Exercise Adherence Program), where you can create your own personal fitness routine;
Ready, Set, Stop!, a smoking cessation program that blends conventional smoking cessation techniques with an interactive
experience; and the Nutrition Center, where you can increase your understanding of your diet and find ways to improve its
nutritional value.

Here’s how to get to “My Health”:
         • Go to www.empireblue.com/nyc.
         • Register or log on to Member Online Services.
         • Click on “My Health” at the top of the screen.
Condition Management Programs – Created to give members a better understanding of their specific health condition, these
voluntary programs help members manage their symptoms and become more self-reliant in order to lead healthier, more active
lives. Members learn the importance of following their doctor’s treatment plan, and by developing emergency plans they can feel
independent and more empowered. All programs are completely voluntary. The level of interaction is based upon the severity of
each member’s condition and their individual need for assistance.

Currently there are 7 programs covering asthma, diabetes, coronary artery disease, chronic obstructive pulmonary disease, impact
conditions, chronic kidney disease, heart failure and rare and chronic diseases.




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 Details and Definitions
In this section, we’ll cover the details you need to know to make the plan work for you. Use it as a reference to understand:
     • Who is eligible for coverage under your plan                    • Your rights to appeal a claim payment or
     • How to file a claim and get your benefits paid                       Medical Management decision
                                                                       • What we mean by certain healthcare terms
Knowing the details can make a difference in how satisfied you are with your plan, and how easy it is for you to use. If you have
additional questions, please visit www.empireblue.com/nyc or call Member Services at 1-800-767-8672.


Eligibility
WHEN ARE YOU ELIGIBLE?
     Your coverage under Empire’s plan begins on:
         • Your group’s effective date; or
         • On the date you are eligible for group benefits as a new employee as determined by your employer.
     Contact your Benefits Administrator for more information on eligibility rules.

ELIGIBLE DEPENDENTS
     The following family members are eligible for coverage under your plan:
         • Your spouse
         • Your unmarried children (including stepchildren)
              − Until the end of the calendar year in which each child reaches age 19, or
              − Until the end of the calendar year in which each child reaches age 23, as long as the child remains unmarried, is
                  dependent on you, and is a registered full-time student at an accredited college or university (a dependent’s full-
                  time attendance at an accredited school of higher education must be documented annually), or
              − Until the child is no longer dependent on you or your spouse, or
              − Until the date of his or her marriage; whichever is earliest
         • Your unmarried children, regardless of age, who are physically or mentally disabled as defined by New York Mental
              Hygiene Law, provided the condition started before the age when coverage would have normally ended. Empire will
              require that a physician certify the child’s condition.
         • Your domestic partner. Please check with your Benefits Administrator for more information.
     Your EPO does not cover foster children.

COVERAGE CATEGORY
     Your coverage category indicates how many people your plan covers. You may choose:
        • Individual, which covers only you
        • Family, which covers you and one or more of the following:
        − Your spouse                             − Unmarried dependent children (natural or adopted)

ADDING OR REMOVING A DEPENDENT
     If you need to change coverage categories or add or remove a dependent, you should contact your Benefits Administrator for
     the appropriate forms. All changes to coverage must be in writing. Life events that might cause you to need to add or remove a
     dependent are:
          • Having a baby
          • Getting married
          • Getting divorced (Spousal coverage ends on the last day of the month following a divorce or annulment.)
          • Having your children reach the age limit for coverage, cease to be dependent on you or get married
     If you failed to enroll when you became eligible, you may enroll yourself or yourself and your dependents without waiting for
     the group’s open enrollment period if you acquire a new dependent as a result of marriage, birth, adoption, or placement for
     adoption (the qualifying event), provided that you apply for such coverage within 30 days after the qualifying event.


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    Your cost for coverage may change if you add a dependent midyear. Any change affecting payment of your premium should
    go through your employer.
    If you or your eligible dependents reject initial enrollment, you and your eligible dependents can become covered for this
    program as follows:
         • You or your eligible dependent was covered under another plan at the time coverage was initially offered, or
         • Coverage was provided in accordance with continuation required by federal or state law and was exhausted, or
         • Coverage under the other plan was subsequently terminated as a result of loss of eligibility for one of the following:
         − Termination of employment                            − Legal separation, divorce or annulment
         − Termination of the other plan                        − Reduction in the number of hours of employment
         − Death of the spouse                                  − Premium payments for the other plan were terminated
    Coverage must be applied for within 30 days of termination for one of the reasons described above.
    If you marry and transfer to family coverage within 60 days of the marriage date, Empire will provide retroactive coverage
    during this period. Otherwise, coverage begins on the date Empire receives and accepts your completed enrollment form from
    your employer during the open enrollment period.
    A newborn natural baby or an adopted baby in certain circumstances (see below) will automatically be covered under the plan
    if you have family coverage. However, you will need to add the baby’s name as a covered dependent. If you do not have
    family coverage but notify Empire in writing within 30 days to change to family coverage, Empire will provide retroactive
    coverage during this period. Otherwise, coverage will begin on the date Empire receives your notice of election form from your
    employer during the open enrollment period.
    An adopted newborn is covered from the moment of birth if:
        • You take custody as soon as the infant is released from the hospital after birth,
        • The newborn is dependent upon you pending finalization of the adoption, and
        • You file an adoption petition with New York State within 30 days of the infant's birth.
    Adopted newborns will not be covered from the moment of birth if:
        • The infant has coverage from one of the natural parents for the newborn’s initial hospital stay
        • A notice revoking the adoption has been filed
        • One of the natural parents revokes their consent to the adoption
    Qualified Medical Child Support Orders (QMCSO). A court order, judgment or decree that:
        • Provides for child support relating to health benefits with respect to the child of a group health plan participant or
             requires health benefit coverage of such child in such plan, and is ordered under state domestic relations law, or
        • Enforces a state medical child support law enacted under Section 1908 of the Social Security Act.
    A Qualified Medical Child Support Order is usually issued when a parent receiving post-divorce custody of the child is not an
    employee.

You may request, without charge, the procedures governing the administration of a Qualified Medical Child Support Order
determination from your Plan Administrator (generally the Employer/Sponsor of the group health plan). Your Plan Administrator
will notify Empire to process the enrollment for the covered person.




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Claims
IF YOU NEED TO FILE A CLAIM
     Empire’s EPO makes healthcare easy by paying providers directly when you stay in-network. Therefore, when you receive
     care from providers or facilities in the Empire or BlueCard PPO networks, you generally do not have to file a claim, as the
     provider files the claim directly with Empire or the local Blue Cross/Blue Shield plan. However, you will have to file a claim
     for reimbursement for covered services if you have a medical emergency out of Empire’s service area. To obtain a claim form,
     call customer service.
         Send completed forms to:
         Hospital Claims:                                                     Medical Claims:
            Empire BlueCross BlueShield                                         Empire BlueCross BlueShield
            P.O. Box 1407                                                       P.O. Box 1407
            Church Street Station                                               Church Street Station
            New York, NY 10008-1407                                             New York, NY 10008-1407
            Attention: Institutional Claims Department                          Attention: Medical Claims Department
     Tips for Filing a Claim
         •    File claims within 18 months of date of service.
         •    Visit www.empireblue.com/nyc to print out a claim form immediately or contact Member Services at 1-800-767-
              8672 to have one mailed to you.
         •    Complete all information requested on the form.
         •    Submit all claims in English or with an English translation.
         •    Attach original bills or receipts. Photocopies will not be accepted.
         •    If Empire is the secondary payer, submit the original or a copy of the primary payer’s Explanation of Benefits (EOB)
              with your itemized bill.
         •    Keep a copy of your claim form and all attachments for your records.
     Want more claim information? Now you can check the status of a claim, view and print Explanation of Benefits (EOB), correct
     certain claim information and more at anytime of day or night just by visiting www.empireblue.com/nyc.

        REMEMBER                       File claims within 18 months of the date of service to receive benefits!

IF YOU HAVE MEDICAL COVERAGE UNDER TWO PLANS (COORDINATION OF BENEFITS―COB)
     Empire has a coordination of benefits (COB) feature that applies when you and members of your family are covered under
     more than one health plan. The benefits provided by Empire will be coordinated with any benefits you are eligible to receive
     under the other plan.
     Together, the plans will pay up to the amount of covered expenses, but not more than the amount of actual expenses.
     When you are covered under two plans, one plan has primary responsibility to pay benefits and the other has secondary
     responsibility. The plan with primary responsibility pays benefits first.
     Which Plan Pays Benefits First?
     Here is how Empire determines which plan has primary responsibility for paying benefits:
         • If the other health plan does not have a coordination of benefits feature, that plan is primary.
         • If you are covered as an employee under the Empire plan and as a dependent under the other plan, your Empire plan
              is primary.
         • For a dependent child covered under both parents’ plans, the primary plan is:
              − The plan of the parent whose birthday comes earlier in the calendar year (month and day)
              − The plan that has covered the parent for a longer period of time, if the parents have the same birthday
              − The father’s plan, if the other plan does not follow the “birthday rule” and uses gender to determine primary
                    responsibility
              − If the parents are divorced or separated (and there is no court decree establishing financial responsibility for the
                    child’s healthcare expenses), the plan covering the parent with custody is primary.
              − If the parent with custody is remarried, his or her plan pays first, the step-parent’s plan pays second and the non-
                    custodial parent’s plan pays third.
              − If the parents are divorced or separated and there is a court decree specifying which parent has financial
                    responsibility for the child’s healthcare expenses, that parent’s plan is primary, once the plan knows about the
                    decree.



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    •    If you are actively employed, your plan is primary in relation to a plan for laid-off or retired employees.
    •    If none of these rules apply, the plan that has covered the patient longest is primary.

If Empire Is the Secondary Plan

If the Empire plan is secondary, then benefits will be reduced so the total benefits paid by both plans will not be greater than the
allowable expenses. Also, Empire will not pay more than the amount Empire would normally pay if Empire were primary.

Tips for Coordinating Benefits
     • To receive all the benefits available to you, file your claim under each plan.
     • File claims first with the primary plan, then with the secondary plan.
     • Include the original or a copy of the Explanation of Benefits (EOB) from the primary plan when you submit your bill
          to the secondary plan. Remember to keep a copy for your records.
If You Receive An Overpayment Of Benefits
If you receive benefits that either should not have been paid, or are more than should have been paid, you must return any
overpayment to Empire within 60 days of receiving it. Overpayments include:
     • Payment for a service not covered by the plan
     • Payment for a person not covered by the plan
     • Payment that exceeds the amount due under your plan
     • Duplicate payments for the same services
Health Care Fraud
Illegal activity adds to everyone’s cost for healthcare. That’s why Empire welcomes your help in fighting fraud. If you know of
any person receiving Empire benefits that they are not entitled to, call us. We will keep your identity confidential. Want to see
some recent examples of Empire’s fraud prevention efforts? Visit www.empireblue.com/nyc.

   REMEMBER                    FRAUD HOTLINE 1-800-I.C.FRAUD (423-7283) During normal business hours

If You Have Questions About a Benefit Payment
Empire reviews each claim for appropriate services and correct information before it is paid. Once a claim is processed, an
Explanation of Benefits (EOB) will be sent directly to you if you have any responsibility on the claim other than your co-
payment amount or if an adjustment is performed on your claim.
If Empire reduces or denies a claim payment, you will receive a written notification or an Explanation of Benefits (EOB) citing
the reasons your claim was reduced or denied.
The notification will give you:
     • The specific reason(s) for the denial
     • References to the pertinent plan provisions on which the denial is based
     • A description of any additional material or information necessary for you to establish the claim and an explanation of
         why this material or information is necessary
     • An explanation of claims review procedures
If you have any questions about your claim, your Benefits Administrator may be able to help you answer them. You may also
contact Empire Member Services at 1-800-767-8672 or in writing for more information. When you call, be sure to have your
Empire I.D. card number handy, along with any information about your claim. Send written inquiries to:
    Empire BlueCross BlueShield
    EPO Member Services
    P.O. Box 1407
    Church Street Station
    New York, NY 10008-1407




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Complaints, Appeals and Grievances
COMPLAINTS
     A complaint is a verbal or written statement of dissatisfaction where Empire is not being asked to review and overturn a
     previous determination. For example: You feel you waited too long for an answer to your letter to Empire. If you have a
     complaint about any of the healthcare services your plan offers, plan procedures or our customer service, call Member
     Services. Member Services may ask you to put your complaint in writing if it is too complex to handle over the telephone.
         Empire BlueCross BlueShield
         P.O. Box 1407
         Church Street Station
         New York, NY 10008-1407
         Attention: Member Services
     If your complaint, grievance or appeal concerns behavioral healthcare, call 1-800-635-6626 or write to:
         Empire BlueCross BlueShield
         P.O. Box 5110
         Grand Central Station
         New York, NY 10163-5110
         Attention: Behavioral Healthcare Program

     Provider Quality Assurance
     Because your healthcare is so important, Empire has a Quality Assurance Program designed to ensure that our network
     providers meet our high standards for care. Through this program, we continually evaluate our network providers.
     If you have a complaint about a network provider’s procedures or treatment decisions, share your concerns directly with your
     provider. If you are still not satisfied, you can submit a complaint at the above address. Empire will refer complaints about the
     clinical quality of the care you receive to the appropriate clinical staff member to investigate.
     We also encourage you to send suggestions to Member Services for improving our policies and procedures. If you have any
     recommendations on improving our policies and procedures, please send them to the Member Services address on the
     previous page.

     Your Right to Appoint a Representative
     You may appoint a representative to act on your behalf if you are not able to submit a complaint, grievance or appeal on your
     own. Call Member Services for a form. When completed forms are returned, we will note the name of your representative’s
     name on our files.

STANDARD INTERNAL APPEALS
     An appeal is a request to review and change an adverse determination (i.e., denied authorization for a service) made by
     Empire’s Medical Management Program or Behavioral Health Management Program that a service is not medically necessary
     or is excluded from coverage because it is considered experimental or investigational.
     Appeals may be filed by telephone or in writing.

     Level 1 Appeals
     A Level 1 Appeal is your first request for review of the initial reduction or denial of services. You have 180 calendar days from
     the date of the notification letter to file an appeal. An appeal submitted beyond the 180-calendar-day limit will not be accepted
     for review.
     If the services have already been provided, Empire will acknowledge receipt of your appeal in writing within 15 calendar days
     from the initial receipt date.
     Qualified clinical professionals who did not participate in the original decision will review your appeal.




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   We will make a decision within the following timeframes for 1st Level Appeals.
      • Precertification. We will complete our review of a precertification appeal (other than an expedited appeal) within 15
           calendar days of receipt of the appeal.
      • Concurrent. We will complete our review of a concurrent appeal (other than an expedited appeal) within 15 calendar
           days of receipt of the appeal.
      • Retrospective. We will complete our review of a retrospective appeal within 30 calendar days of receipt of the
           appeal.
   We will provide a written notice of our determination to you or your representative, and your provider, within two business
   days of reaching a decision.
   If Empire’s Medical Management Program does not make a decision within 60 calendar days of receiving all necessary
   information to review your appeal, Empire will approve the service.
   If you are dissatisfied with the outcome of your Level 1 Appeal, you have the right to file a Level 2 Appeal, or the right to file
   an External Appeal through the New York State Department of Insurance.
                        A Level 1 Appeal submitted beyond the 180-calendar-day limit will not be accepted for review.
      REMEMBER
                        A Level 2 Appeal submitted beyond the 60-business-day limit will not be accepted for review.

   Expedited Level 1 Appeals
   You can file an expedited Level 1 Appeal and receive a quicker response if:
        • You want to continue healthcare services, procedures or treatments that have already started
        • You need additional care during an ongoing course of treatment
        • Your provider believes an immediate appeal is warranted because delay in treatment would pose an imminent or
            serious threat to your health or ability to regain maximum function, or would subject you to severe pain that cannot be
            adequately managed without the care or treatment that is the subject of the claim.
   Expedited Appeals may be filed by telephone and in writing.
   Please note that appeals of claims decisions made after the service has been provided cannot be expedited. When you file an
   expedited appeal, Empire will respond as quickly as possible given the medical circumstances of the case, subject to the
   following maximum timeframes:
       •     You or your provider will have reasonable access to our clinical reviewer within one business day of Empire’s receipt
             of the request.
        • Empire will make a decision within two business days of receipt of all necessary information but in any event within
             72 hours of receipt of the appeal.
        • Empire will notify you immediately of the decision by telephone, and within 48 hours in writing.
   If you are dissatisfied with the outcome of your Level 1 Expedited Appeal, you may request an external review by a New York
   State Department of Insurance appeals agent. For more details see the explanation of External Appeals.
   If Empire’s Medical Management Program does not make a decision within 2 business days of receiving all necessary
   information to review your appeal, Empire will approve the service.

   Level 2 Appeals and Timeframes
   If you are dissatisfied with the outcome of your Level 1 Appeal, you may file a Level 2 Appeal with Empire within 60 business
   days from the receipt of the notice of the letter denying your Level 1 Appeal. If the appeal is not submitted within that
   timeframe, we will not review it and our decision on the Level 1 appeal will stand. Appeals may be filed by telephone and
   in writing.
   We will make a decision within the following timeframes for 2nd Level appeals:
        • Precertification. We will complete our review of a precertification appeal within 15 calendar days of receipt of the
             appeal.
        • Concurrent. We will complete our review of a concurrent appeal within 15 calendar days of receipt of the appeal.
        • Retrospective. We will complete our review of a retrospective appeal within 30 calendar days of receipt of the appeal.


EXTERNAL APPEALS
   As an alternative to filing a Level 2 Appeal with Empire, you may request an external review by a New York State Department
   of Insurance appeals agent. You can file an external appeal if benefits were denied:
        • For lack of medical necessity
        • Because the service was determined to be an experimental and/or investigational procedure
   External appeals can also substitute for a Level 1 Appeal with Empire if you and Empire jointly agree to waive Empire’s
   internal appeal process and proceed directly to the external appeal process.



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     To Obtain An External Appeal
     You will receive an external appeal application when you receive the adverse determination from Empire regarding your Level
     1 Appeal. For more information or an appeal application, contact one of the following:
         • The New York State Department of Insurance at 1-800-400-8882 or www.ins.state.ny.us
         • Empire Member Services at 1-800-767-8672
     Resolving an External Appeal
     A New York State Department of Insurance appeal agent will review your request and decide if the denied service is medically
     necessary and should be covered by Empire. The agent’s decision is final and binding on both you and Empire.
     The application will provide clear instructions for completion. Empire does not charge a fee for the filing of an external appeal.
     Send your external appeal application to the New York State Department of Insurance, as stated on the form. Do not send the
     application to Empire. You and your doctor must release all pertinent medical information about your medical condition and
     request for services.
     Submit your appeal within 45 calendar days:
          • From the date you received the adverse determination from the Level 1 internal appeal.
          • From the date that you and Empire agree to waive Empire’s internal appeals process.
     You will lose your right to an external appeal if you do not file an application for an external appeal within 45 days
     from your receipt of the final adverse determination from the first level internal plan appeal or the date Empire agreed
     to waive the internal appeal process.
     If you have any questions regarding external appeals, please call Empire’s Medical Management Program at 1-800-553-9603.
     Note that the number only responds to inquiries about external appeals.
     Standard External Review Process
     Standard external appeals will be decided according to the following timeframes:
         • An external appeal agent must decide an external standard appeal within 30 calendar days of receiving your
              application for an external appeal.
         • Five additional business days may be added if the agent needs additional information.
         • If the agent determines that the information submitted is materially different from that considered by the plan, the plan
              will have three additional days to reconsider or affirm its decision.
         • You and the plan will be notified within two business days of the external review agent’s decision.

     Expedited External Appeals
     An expedited external appeal may be requested if your doctor can attest that a delay in providing the recommended treatment
     would pose an imminent or serious threat to your health. In this case, the following timeframe applies:
         • The agent will make a decision within three calendar days.
         • Every reasonable effort will be made by the agent to notify you and Empire within two business days by telephone or
             fax. A written notice will also be sent immediately by the agent.
LEVEL 1 GRIEVANCES
     A grievance is a verbal or written request to review an adverse determination concerning an administrative decision not related
     to medical necessity. For example, a claim was denied because the member did not obtain precertification for services.
     A Level 1 Grievance is your first request for review of Empire’s administrative decision. You have 180 calendar days from the
     receipt of the notification letter to file a grievance. A grievance submitted beyond the 180-calendar-day limit will not be
     accepted for review.
     If the services have already been provided, Empire will acknowledge your grievance in writing within 15 calendar days from
     the date Empire received your grievance. The written acknowledgement will include the name, address, and telephone number
     of the department that will respond to the grievance, and a description of any additional information required to complete the
     review.

     We will make a decision within the following timeframes for 1st Level Grievances:
        • Pre-service (services have not yet been rendered). We will complete our review of a pre-service grievance (other than
             an expedited grievance) within 15 calendar days of receipt of the grievance.
        • Post-service (services have already been rendered). We will complete our review of a post-service grievance within
             30 calendar days of receipt of the grievance.




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LEVEL 2 GRIEVANCES
   If you are dissatisfied with the outcome of your Level 1 Grievance, you may file a Level 2 Grievance with Empire within 60
   business days from receipt of the notice of the letter denying your Level 1 Grievance. If the Level 2 Grievance is not submitted
   within that timeframe, we will not review it and the decision on the Level 1 Grievance will stand. We will acknowledge receipt
   of the 2nd Level Grievance within 15 days of receiving the grievance. The written acknowledgement will include the name,
   address and telephone numbers of the department that will respond to the grievance. A qualified representative (including
   clinical personnel, where appropriate) who did not participate in the Level 1 Grievance decision will review the Level 2
   Grievance.
   We will make a decision within the following timeframes for 2nd Level Grievances:
        • Pre-service. We will complete our review of a pre-service grievance within 15 calendar days of receipt of the
             grievance.
        • Post-service. We will complete our review of a post-service grievance within 30 calendar days of receipt of the
             grievance.

EXPEDITED GRIEVANCES
   You can file an expedited Level 1 or Level 2 Grievance and receive a quicker response if a delay in resolution of the grievance
   would pose an imminent or serious threat to your health or ability to regain maximum function, or would subject you to severe
   pain that cannot be adequately managed without the care or treatment that is the subject of the claim.
   Expedited Grievances may be filed by telephone and in writing. When you file an expedited grievance, Empire will respond as
   soon as possible considering the medical circumstances of the case, subject to the following maximum timeframes:
        • Empire will make a decision within 48 hours of receipt of all necessary information, but in any event within 72 hours
             of receipt of the grievance.
        • Empire will notify you immediately of the decision by telephone, and within two business days in writing.

DECISION ON GRIEVANCES
   Empire’s notice of its Grievance decision (whether standard or urgent) will include:
      • The reason for Empire’s decision
      • The clinical rationale, if appropriate, and
      • For Level 1 Grievances, instructions on how to file a Level 2 Grievance if you are not satisfied with the decision

HOW TO FILE AN APPEAL OR GRIEVANCE
   To submit an appeal or grievance, call Member Services at 1-800-767-8672 or write to the following address with the reason
   why you believe the administrative decision was wrong. Please submit any data to support your request and include your
   member ID number and, if applicable, claim number and date of service.
   The address for filing an appeal or grievance is:
       Empire BlueCross BlueShield
       Appeal and Grievance Department
       P.O. Box 1407
       Church Street Station
       New York, NY 10008-1407




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Ending and Continuing Coverage
WHEN COVERAGE ENDS
     Your plan coverage may terminate for any of the following reasons:
        • Your group terminates the contract
        • Your employer no longer meets our underwriting standards
        • Your employer fails to pay premiums
        • You fail to pay premiums (if required)
        • The covered employee dies
        • You or your covered dependents no longer meet your employer’s or the contract’s eligibility requirements
        • You or your covered dependents have made a false statement on an application for coverage or on a health insurance
             claim form, or you or your group have otherwise engaged in fraud
        • Empire discontinues this class of coverage

NOTICE OF CONTINUATION COVERAGE RIGHTS UNDER COBRA

WHAT IS CONTINUATION COVERAGE?
Federal law requires that most group health plans (including this Plan) give employees and their families the opportunity to continue
their health care coverage when there is a “qualifying event” that would result in a loss of coverage under an employer’s plan.
Depending on the type of qualifying event, “qualified beneficiaries” can include the employee (or retired employee) covered under
the group health plan, the covered employee’s spouse, and the dependent children of the covered employee. To be eligible, a
qualified beneficiary must be enrolled in the plan on the day before the qualifying event. A child who is born to or placed for
adoption with the covered employee during a period of COBRA coverage will be eligible to become a qualified beneficiary. In
accordance with the terms of the Plan and the requirements of the federal law, these qualified beneficiaries can be added to COBRA
coverage upon proper notification to Plan Administrator of the birth or adoption.
Continuation coverage is the same coverage that the Plan gives to other participants or beneficiaries under the Plan who are not
receiving continuation coverage. Each qualified beneficiary who elects continuation coverage will have the same rights under the
Plan as other participants or beneficiaries covered under the Plan, including: open enrollment and special enrollment rights.
                   HOW LONG WILL CONTINUATION COVERAGE LAST?
                   In the case of a loss of coverage due to end of employment or reduction in hours of employment, coverage
                   generally may be continued only for up to a total of 18 months. In the case of losses of coverage due to an
                   employee’s death, divorce or legal separation, the employee’s becoming entitled to Medicare benefits or a
                   dependent child ceasing to be a dependent under the terms of the plan, coverage may be continued for up to a
                   total of 36 months. When the qualifying event is the end of employment or reduction of the employee's hours of
                   employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying
                   event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months
                   after the date of Medicare entitlement.
                   Continuation coverage will be terminated before the end of the maximum period if:
                   any required premium is not paid in full on time,
                   a qualified beneficiary becomes covered, after electing continuation coverage, under another group health plan
                   that does not impose any pre-existing condition exclusion for a pre-existing condition of the qualified
                   beneficiary,
                   a qualified beneficiary becomes entitled to Medicare benefits (under Part A, Part B, or both) after electing
                   continuation coverage, or
                   the employer ceases to provide any group health plan for its employees.
                   Continuation coverage may also be terminated for any reason the Plan would terminate coverage of a participant
                   or beneficiary not receiving continuation coverage (such as fraud).

HOW CAN YOU EXTEND THE LENGTH OF COBRA CONTINUATION COVERAGE?
If you elect continuation coverage, an extension of the maximum period of coverage may be available if a qualified beneficiary is
disabled or a second qualifying event occurs. You must notify ,. Your personnel office if you are actively employed or the NYC
Health Benefits program if you are retired of a disability or a second qualifying event in order to extend the period of continuation
coverage. Failure to provide notice of a disability or second qualifying event may affect the right to extend the period of
continuation coverage.
Employees and/ or eligible family members can obtain application forms by contacting the NYC Health Benefits Program.




44                                                     www.empireblue.com
Disability
An 11-month extension of coverage may be available if any of the qualified beneficiaries is determined by the Social Security
Administration (SSA) to be disabled. The disability has to have started at some time before the 60th day of COBRA continuation
coverage and must last at least until the end of the 18-month period of continuation coverage. Contact your plan administrator for
additional information. Each qualified beneficiary who has elected continuation coverage will be entitled to the 11-month disability
extension if one of them qualifies. If the qualified beneficiary is determined by SSA to no longer be disabled, you must notify the
Plan Administrator of that fact within 30 days after SSA’s determination.
Second Qualifying Event
An 18-month extension of coverage will be available to spouses and dependent children who elect continuation coverage if a
second qualifying event occurs during the first 18 months of continuation coverage. The maximum amount of continuation
coverage available when a second qualifying event occurs is 36 months. Such second qualifying events may include the death of a
covered employee, divorce or separation from the covered employee, the covered employee’s becoming entitled to Medicare
benefits (under Part A, Part B, or both), or a dependent child’s ceasing to be eligible for coverage as a dependent under the Plan.
These events can be a second qualifying event only if they would have caused the qualified beneficiary to lose coverage under the
Plan if the first qualifying event had not occurred. You must notify the Plan within 60 days after a second qualifying event occurs if
you want to extend your continuation coverage.
How can you elect COBRA continuation coverage?
To elect continuation coverage, you must complete the Cobra Continuation Coverage Election Form available from your Plan
Administrator and furnish it according to the directions on the form. Each qualified beneficiary has a separate right to elect
continuation coverage. For example, the employee’s spouse may elect continuation coverage even if the employee does not.
Continuation coverage may be elected for only one, several, or for all dependent children who are qualified beneficiaries. A parent
may elect to continue coverage on behalf of any dependent children. The employee or the employee's spouse can elect continuation
coverage on behalf of all of the qualified beneficiaries.
In considering whether to elect continuation coverage, you should take into account that a failure to continue your group health
coverage will affect your future rights under federal law. First, you can lose the right to avoid having pre-existing condition
exclusions applied to you by other group health plans if you have more than a 63-day gap in health coverage, and election of
continuation coverage may help you not have such a gap. Second, you will lose the guaranteed right to purchase individual health
insurance policies that do not impose such pre-existing condition exclusions if you do not get continuation coverage for the
maximum time available to you. Finally, you should take into account that you have special enrollment rights under federal law.
You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan
sponsored by your spouse’s employer) within 30 days after your group health coverage ends because of the qualifying event listed
above. You will also have the same special enrollment right at the end of continuation coverage if you get continuation coverage
for the maximum time available to you.
How much does COBRA continuation coverage cost?
Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage. The amount a qualified
beneficiary may be required to pay may not exceed 102 percent (or, in the case of an extension of continuation coverage due to a
disability, 150 percent) of the cost to the group health plan (including both employer and employee contributions) for coverage of a
similarly situated plan participant or beneficiary who is not receiving continuation coverage. Contact your Plan Administrator for
additional information.

[For employees eligible for trade adjustment assistance: The Trade Act of 2002 created a new tax credit for certain individuals
who become eligible for trade adjustment assistance and for certain retired employees who are receiving pension payments from the
Pension Benefit Guaranty Corporation (PBGC) (eligible individuals). Under the new tax provisions, eligible individuals can either
take a tax credit or get advance payment of 65% of premiums paid for qualified health insurance, including continuation coverage.
If you have questions about these new tax provisions, you may call the Health Coverage Tax Credit Customer Contact Center toll-
free at 1-866-628-4282. TTD/TTY callers may call toll-free at 1-866-626-4282. More information about the Trade Act is also
available at www.doleta.gov/tradeact/2002act_index.asp.
When and how must payment for COBRA continuation coverage be made?
If you elect continuation coverage, you do not have to send any payment with the Election Form. However, you must make your
first payment for continuation coverage not later than 45 days after the date of your election. (This is the date the Election Notice is
post-marked, if mailed.) If you do not make your first payment for continuation coverage in full not later than 45 days after the date
of your election, you will lose all continuation coverage rights under the Plan. You are responsible for making sure that the amount
of your first payment is correct. You may contact your Plan Administrator or other party responsible for COBRA administration
under the Plan to confirm the correct amount of your first payment.
After you make your first payment for continuation coverage, you will be required to make periodic payments for each subsequent
coverage period. The amount due for each coverage period for each qualified beneficiary is shown in the Election Notice. If you
fail to make a periodic payment before the end of any applicable grace period for that coverage period, you will lose all rights to
continuation coverage under the Plan.
For more information



                                                        www.empireblue.com                                                           45
This notice does not fully describe continuation coverage or other rights under the Plan. More information about continuation
coverage and your rights under the Plan is available from the Plan Administrator.
For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act
(HIPAA), and other laws affecting group health plans, contact the U.S. Department of Labor’s Employee Benefits Security
Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional
and District EBSA Offices are available through EBSA’s website.)
Keep Your Plan Informed of Address Changes
In order to protect your and your family’s rights, you should keep the Plan Administrator informed of any changes in your address
and the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan
Administrator.



PLAN CONTACT INFORMATION
     For information about your plan and Cobra continuation of coverage active employees should contact their
     personel office

     For information about your plan and COBRA continuation of coverage retirees should contact:

     NYC Health Benefits Program
     40 Rector Street 3rd Floor
     New York, NY 10006
     212-306-7753

     A sample COBRA Notice and Election Form provided by the U.S. Department of Labor can be found on pages
     47-52.




46                                                   www.empireblue.com
Below is a sample of the COBRA Continuation Coverage Election form.

MODEL COBRA CONTINUATION COVERAGE ELECTION NOTICE
(For use by single-employer group health plans)

Enter date of notice

Dear Identify the qualified beneficiary(ies), by name or status:

This notice contains important information about your right to continue your health care
coverage in the enter name or group health plan (the Plan). Please read the information contained in
this notice very carefully.
LA
To elect COBRA continuation coverage, follow the instructions on the next page to complete the
enclosed Election Form and submit it to us.

If you do not elect COBRA continuation coverage, your coverage under the Plan will end on enter date
due to [check appropriate box]:

           End of employment                     Reduction in hours of employment
           Death of employee                     Divorce or legal separation
           Entitlement to Medicare               Loss of dependent child status

Each person (“qualified beneficiary”) in the category(ies) checked below is entitled to elect COBRA
continuation coverage, which will continue group health care coverage under the Plan for up to enter 18
or 36, as appropriate months [check appropriate box or boxes; names may be added]:

           Employee or former employee
           Spouse or former spouse
           Dependent child(ren) covered under the Plan on the day before the event that caused the loss
       of coverage
           Child who is losing coverage under the Plan because he or she is no longer a dependent under
       the Plan

If elected, COBRA continuation coverage will begin on enter date and can last until enter date..
[Add, if appropriate: You may elect any of the following options for COBRA continuation coverage:
[list available coverage options].

COBRA continuation coverage will cost: enter amount each qualified beneficiary will be required to pay
for each option per month of coverage and any other permitted coverage periods. You do not have to
send any payment with the Election Form. Important additional information about payment for COBRA
continuation coverage is included in the pages following the Election Form.

If you have any questions about this notice or your rights to COBRA continuation coverage, you should
contact enter name of party responsible for COBRA administration for the Plan, with telephone number
and address.




                                            www.empireblue.com                                         47
COBRA CONTINUATION COVERAGE ELECTION FORM




INSTRUCTIONS: To elect COBRA continuation coverage, complete this Election Form and return
it to us. Under federal law, you must have 60 days after the date of this notice to decide whether you
want to elect COBRA continuation coverage under the Plan.

Send completed Election Form to: [Enter Name and Address]

This Election Form must be completed and returned by mail [or describe other means of submission and
due date]. If mailed, it must be post-marked no later than [enter date].

If you do not submit a completed Election Form by the due date shown above, you will lose your right
to elect COBRA continuation coverage. If you reject COBRA continuation coverage before the due
date, you may change your mind as long as you furnish a completed Election Form before the due date.
However, if you change your mind after first rejecting COBRA continuation coverage, your COBRA
continuation coverage will begin on the date you furnish the completed Election Form.

Read the important information about your rights included in the pages after the Election Form.

I (We) elect COBRA continuation coverage in the [enter name of plan] (the Plan) as indicated
below:

     Name        Date of Birth        Relationship to Employee         SSN (or other identifier)

a. _________________________________________________________________________
       [Add if appropriate: Coverage option elected: _______________________________]
b. _________________________________________________________________________
       [Add if appropriate: Coverage option elected: _______________________________]
c. _________________________________________________________________________
       [Add if appropriate: Coverage option elected: _______________________________]



_____________________________________                 _____________________________
Signature                                             Date

______________________________________                _____________________________
Print Name                                            Relationship to individual(s) listed above

______________________________________
______________________________________
______________________________________                ______________________________
Print Address                                         Telephone number




48                                          www.empireblue.com
IMPORTANT INFORMATION

ABOUT YOUR COBRA CONTINUATION COVERAGE RIGHTS

WHAT IS CONTINUATION COVERAGE?
Federal law requires that most group health plans (including this Plan) give employees and their families the opportunity to
continue their health care coverage when there is a “qualifying event” that would result in a loss of coverage under an
employer’s plan. Depending on the type of qualifying event, “qualified beneficiaries” can include the employee (or retired
employee) covered under the group health plan, the covered employee’s spouse, and the dependent children of the covered
employee.
Continuation coverage is the same coverage that the Plan gives to other participants or beneficiaries under the Plan who are not
receiving continuation coverage. Each qualified beneficiary who elects continuation coverage will have the same rights under
the Plan as other participants or beneficiaries covered under the Plan, including [add if applicable: open enrollment and]
special enrollment rights.

HOW LONG WILL CONTINUATION COVERAGE LAST?
In the case of a loss of coverage due to end of employment or reduction in hours of employment, coverage generally
may be continued only for up to a total of 18 months. In the case of losses of coverage due to an employee’s death,
divorce or legal separation, the employee’s becoming entitled to Medicare benefits or a dependent child ceasing to be a
dependent under the terms of the plan, coverage may be continued for up to a total of 36 months. When the qualifying
event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled
to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified
beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. This notice shows the
maximum period of continuation coverage available to the qualified beneficiaries.
Continuation coverage will be terminated before the end of the maximum period if:
          • any required premium is not paid in full on time,
          • a qualified beneficiary becomes covered, after electing continuation coverage, under another group health plan
              that does not impose any pre-existing condition exclusion for a pre-existing condition of the qualified
              beneficiary,
          • a qualified beneficiary becomes entitled to Medicare benefits (under Part A, Part B, or both) after electing
              continuation coverage, or
          • the employer ceases to provide any group health plan for its employees.
Continuation coverage may also be terminated for any reason the Plan would terminate coverage of a participant or beneficiary
not receiving continuation coverage (such as fraud).

[If the maximum period shown on page 1 of this notice is less than 36 months, add the following three paragraphs:]

HOW CAN YOU EXTEND THE LENGTH OF COBRA CONTINUATION COVERAGE?
If you elect continuation coverage, an extension of the maximum period of coverage may be available if a qualified beneficiary
is disabled or a second qualifying event occurs. You must notify enter name of party responsible for COBRA administration
of a disability or a second qualifying event in order to extend the period of continuation coverage. Failure to provide notice of
a disability or second qualifying event may affect the right to extend the period of continuation coverage.

DISABILITY
An 11-month extension of coverage may be available if any of the qualified beneficiaries is determined by the Social Security
Administration (SSA) to be disabled. The disability has to have started at some time before the 60th day of COBRA
continuation coverage and must last at least until the end of the 18-month period of continuation coverage. Describe Plan
provisions for requiring notice of disability determination, including time frames and procedures. Each qualified beneficiary
who has elected continuation coverage will be entitled to the 11-month disability extension if one of them qualifies. If the
qualified beneficiary is determined by SSA to no longer be disabled, you must notify the Plan of that fact within 30 days after
SSA’s determination.

SECOND QUALIFYING EVENT
An 18-month extension of coverage will be available to spouses and dependent children who elect continuation coverage if a
second qualifying event occurs during the first 18 months of continuation coverage. The maximum amount of continuation
coverage available when a second qualifying event occurs is 36 months. Such second qualifying events may include the death


                                                       www.empireblue.com                                                           49
of a covered employee, divorce or separation from the covered employee, the covered employee’s becoming entitled to
Medicare benefits (under Part A, Part B, or both), or a dependent child’s ceasing to be eligible for coverage as a dependent
under the Plan. These events can be a second qualifying event only if they would have caused the qualified beneficiary to lose
coverage under the Plan if the first qualifying event had not occurred. You must notify the Plan within 60 days after a second
qualifying event occurs if you want to extend your continuation coverage.

HOW CAN YOU ELECT COBRA CONTINUATION COVERAGE?
To elect continuation coverage, you must complete the Election Form and furnish it according to the directions on the form.
Each qualified beneficiary has a separate right to elect continuation coverage. For example, the employee’s spouse may elect
continuation coverage even if the employee does not. Continuation coverage may be elected for only one, several, or for all
dependent children who are qualified beneficiaries. A parent may elect to continue coverage on behalf of any dependent
children. The employee or the employee's spouse can elect continuation coverage on behalf of all of the qualified
beneficiaries.
In considering whether to elect continuation coverage, you should take into account that a failure to continue your group health
coverage will affect your future rights under federal law. First, you can lose the right to avoid having pre-existing condition
exclusions applied to you by other group health plans if you have more than a 63-day gap in health coverage, and election of
continuation coverage may help you not have such a gap. Second, you will lose the guaranteed right to purchase individual
health insurance policies that do not impose such pre-existing condition exclusions if you do not get continuation coverage for
the maximum time available to you. Finally, you should take into account that you have special enrollment rights under
federal law. You have the right to request special enrollment in another group health plan for which you are otherwise eligible
(such as a plan sponsored by your spouse’s employer) within 30 days after your group health coverage ends because of the
qualifying event listed above. You will also have the same special enrollment right at the end of continuation coverage if you
get continuation coverage for the maximum time available to you.

HOW MUCH DOES COBRA CONTINUATION COVERAGE COST?
Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage. The amount a qualified
beneficiary may be required to pay may not exceed 102 percent (or, in the case of an extension of continuation coverage due to
a disability, 150 percent) of the cost to the group health plan (including both employer and employee contributions) for
coverage of a similarly situated plan participant or beneficiary who is not receiving continuation coverage. The required
payment for each continuation coverage period for each option is described in this notice.
[If employees might be eligible for trade adjustment assistance, the following information may be added: The Trade Act of
2002 created a new tax credit for certain individuals who become eligible for trade adjustment assistance and for certain retired
employees who are receiving pension payments from the Pension Benefit Guaranty Corporation (PBGC) (eligible individuals).
Under the new tax provisions, eligible individuals can either take a tax credit or get advance payment of 65% of premiums
paid for qualified health insurance, including continuation coverage. If you have questions about these new tax provisions, you
may call the Health Coverage Tax Credit Customer Contact Center toll-free at 1-866-628-4282. TTD/TTY callers may call
toll-free at 1-866-626-4282. More information about the Trade Act is also available at
www.doleta.gov/tradeact/2002act_index.asp.

WHEN AND HOW MUST PAYMENT FOR COBRA CONTINUATION COVERAGE BE MADE?
First payment for continuation coverage
If you elect continuation coverage, you do not have to send any payment with the Election Form. However, you must make
your first payment for continuation coverage not later than 45 days after the date of your election. (This is the date the Election
Notice is post-marked, if mailed.) If you do not make your first payment for continuation coverage in full not later than 45
days after the date of your election, you will lose all continuation coverage rights under the Plan. You are responsible for
making sure that the amount of your first payment is correct. You may contact enter appropriate contact information, e.g., the
Plan Administrator or other party responsible for COBRA administration under the Plan to confirm the correct amount of your
first payment.
Periodic payments for continuation coverage
After you make your first payment for continuation coverage, you will be required to make periodic payments for each
subsequent coverage period. The amount due for each coverage period for each qualified beneficiary is shown in this notice.
The periodic payments can be made on a monthly basis. Under the Plan, each of these periodic payments for continuation
coverage is due on the enter due day for each monthly payment for that coverage period. [If Plan offers other payment
schedules, enter with appropriate dates: You may instead make payments for continuation coverage for the following
coverage periods, due on the following dates:]. If you make a periodic payment on or before the first day of the coverage
period to which it applies, your coverage under the Plan will continue for that coverage period without any break. The Plan
[select one: will or will not] send periodic notices of payments due for these coverage periods.
Grace periods for periodic payments
Although periodic payments are due on the dates shown above, you will be given a grace period of 30 days after the first day
of the coverage period [or enter longer period permitted by Plan] to make each periodic payment. Your continuation coverage


50                                                      www.empireblue.com
will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace
period for that payment. [If Plan suspends coverage during grace period for nonpayment, enter and modify as necessary:
However, if you pay a periodic payment later than the first day of the coverage period to which it applies, but before the end of
the grace period for the coverage period, your coverage under the Plan will be suspended as of the first day of the coverage
period and then retroactively reinstated (going back to the first day of the coverage period) when the periodic payment is
received. This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to
be resubmitted once your coverage is reinstated.
If you fail to make a periodic payment before the end of the grace period for that coverage period, you will lose all rights to
continuation coverage under the Plan.
Your first payment and all periodic payments for continuation coverage should be sent to:
[enter appropriate payment address]

FOR MORE INFORMATION
This notice does not fully describe continuation coverage or other rights under the Plan. More information about continuation
coverage and your rights under the Plan is available in your summary plan description or from the Plan Administrator.
If you have any questions concerning the information in this notice, your rights to coverage, or if you want a copy of your
summary plan description, you should contact [ enter name of party responsible for COBRA administration for the Plan, with
telephone number and address].
For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability
Act (HIPAA), and other laws affecting group health plans, contact the U.S. Department of Labor’s Employee Benefits
Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers
of Regional and District EBSA Offices are available through EBSA’s website.)

KEEP YOUR PLAN INFORMED OF ADDRESS CHANGES
In order to protect your and your family’s rights, you should keep the Plan Administrator informed of any changes in your
address and the addresses of family members. You should also keep a copy, for your records, of any notices you send to the
Plan Administrator.




                                                       www.empireblue.com                                                           51
CONTINUING COVERAGE UNDER NEW YORK STATE LAW
     If you are not entitled to continuation of coverage under COBRA (for example, your employer has fewer than 20 employees),
     you may be entitled to continue coverage under New York State Law. These laws vary from those under COBRA, but
     generally also require continued coverage for up to 18, 29 or 36 months.
     Call or write to your employer or Empire to find out if you are entitled to continuation of coverage under the New York State
     Insurance Law.

THE VETERANS BENEFITS IMPROVEMENT ACT OF 2004
     The Veterans Benefits Improvement Act of 2004, which amends the 1994 Uniformed Services Employment and
     Reemployment Rights Act (USERRA), extends the period for continuation of health care coverage as follows:
     If a covered person's health plan coverage would terminate because of an absence due to military service, the person may elect
     to continue the health plan coverage for up to 24 months after the absence begins or for the period of service. Similar to
     COBRA, the person cannot be required to pay more than 102 percent (except where State requirements provide for a lesser
     amount) of the full premium for the coverage. If military service was for 30 or fewer days, the person cannot be required to
     pay more than the normal employee share of any premium.

RESERVISTS SUPPLEMENTARY CONTINUATION AND CONVERSION
     If the group’s plan qualifies as an employer group heath plan subject to federal continuation of coverage provision of COBRA,
     previously described, the supplementary continuation and conversion right described in this section does not apply.
     • If a covered member who is a member of a reserve component of the armed forces of the United States, including the
          National Guard, enters upon active duty and the group does not voluntarily maintain coverage for such member, coverage
          will be suspended unless the member elects in writing, within 60 days of being ordered to active duty, to continue
          coverage under this program for the covered member and their eligible covered dependents. Such continued coverage
          shall not be subject to evidence of insurability. The member must pay the group the required group rate premium in
          advance, but more frequently than once a month.
     • Reservists’ supplementary continuation will not be available to any person who is, could be, covered by Medicare or any
          other group coverage. Coverage available to active duty members of the armed forces will not be considered group
          coverage for the above purposes.
     • In the event that the Member is re-employed or restored to participation in the Group upon return to civilian status after the
          period of continuation of coverage or suspension, the member will be entitled to resume coverage under program for the
          member and eligible dependents. If coverage has been suspended, resumed coverage will be retroactive to the date of
          termination of active duty. No exclusion or waiting period will be imposed in connection with resumed coverage except
          regarding:
               − a condition that arose during the period of active duty and that has been determined by the Secretary of Veterans
                    Affairs to be a condition incurred in the line of duty; or
               − a waiting period imposed that had not been completed prior to the period of suspension. The sum of the waiting
                    periods imposed prior and subsequent to the suspension shall not exceed eleven months.
     In the event that the covered member is not re-employed or restored to participation in the group upon return to civilian status,
     the member shall have the right within 31 days of the termination of active duty, or discharge from hospitalization, incident to
     active duty which continues for a period of not more than one (1) year, to submit a written request for continuation to the
     group, or a request for conversion directly to Empire, as described in this booklet. Such individual conversion policy will be
     effective on the day after the end of the period of supplementary continuation. If the member elects supplementary
     continuation or if coverage is suspended, the supplementary conversion right will be available to the member’s spouse if
     divorce or annulment of the marriage occurs during the period of active duty, and, in the event the member dies while on active
     duty, to the member’s spouse and children, and to each individually upon attaining the limiting age of coverage under this
     program, but not the child’s dependents.

CONVERTING YOUR COVERAGE
     Under certain circumstances, you can convert your group coverage to individual coverage with comparable benefits. Or, you
     can convert your group coverage to a Medicare supplement policy, if appropriate. However, not all your current benefits may
     be available when you convert your coverage.
     You may convert your group coverage under any of these circumstances:
          • You, your spouse or dependent child no longer qualifies as a family member under the contract because:
              − Your child no longer qualifies as a covered dependent
              − Your covered incapacitated child no longer qualifies as incapacitated
              − Your spouse divorces or annuls your marriage
              − You die



52                                                     www.empireblue.com
       •    You no longer qualify as a group member
       •    Your company no longer meets our underwriting standards
       •    Your company terminates the contract and does not offer replacement coverage to group members
       •    You are a member or the spouse of a member and have elected Medicare as your primary coverage
   You must advise your company before you or a covered dependent is no longer eligible for coverage, so Empire can continue
   coverage under a conversion contract. If more than 63 calendar days elapses between your old and new coverage, you will
   have to satisfy a new waiting period.

   To convert your coverage, you must:
       •    Be a New York State resident within Empire’s operating area,
       •    Apply within 90 calendar days of the date your group contract terminates (application timeframes may vary; please
            refer to your contract or see your Benefits Administrator), and
       •    Pay the premiums for the conversion contract when due.
   To request an application or obtain additional information on converting your coverage, call 1-800-261-5962.
   If you are converting to a Medicare Supplement policy, and you live outside New York State, you should contact your local
   Blue Cross or Blue Shield plan.
   You may not convert your group coverage, if coverage ends because:
       •    You fraudulently filed the Notice of Election
       •    You were never a legitimate group member
       •    The group replaced this contract with similar continuous coverage from another insurance carrier
       •    You filed false or improper claims, or for any other similar reasons approved by the Insurance Department


ENDING AND CONTINUING COVERAGE
   Your Employer/Plan Sponsor reserves the right to amend or terminate its group health plan coverage provided to you at any
   time without prior notice or approval. The decision to end or amend the health plan coverage may be due to changes in federal
   or state laws governing welfare benefits, the requirements of the Internal Revenue Code or ERISA, or any other reason.

   An amendment or termination may apply to all or any portion of the group health plan coverage and to all or to only a portion
   of the participants and beneficiaries.


PORTABILITY OF COVERAGE
   Your contract may require an 11-month waiting period before paying benefits for pre-existing conditions. At the same time you
   may be eligible for credit toward the satisfaction of this waiting period. If you had similar coverage (hospital, medical or major
   medical) from another insurance carrier before the effective date of your Empire coverage, you will receive credit for whatever
   waiting period you met under the prior contract (Creditable Coverage). The pre-existing condition provision in your Empire
   contract provides that credit towards the pre-existing condition waiting period will be given for the time you were previously
   covered under Creditable Coverage of a prior plan, if the previous Creditable Coverage was continuous to a date not more than
   63 days prior to the enrollment date under your Empire plan.
   Please note that you have a right to request a certificate of Creditable Coverage from a prior plan or issuer, free of charge, and
   that Empire will assist you in obtaining a certificate from any prior plan or issuer, if necessary.
   To determine whether you are eligible for portability of coverage, you must provide Empire with the certificate of Creditable
   Coverage or a letter of proof from the prior carrier or group that contains the covered person’s name, contract type, start and
   end dates of coverage, and names of covered dependents. The evidence of prior coverage should be submitted immediately to
   avoid possible claim rejections.

IF YOU BECOME DISABLED
   If you or your covered dependent is totally disabled when coverage ends, coverage will continue for the disabled person for
   expenses related to the injury or illness that caused the disability. These benefits may continue for a period of twelve months
   following the date coverage ended.
   Coverage will end when the disabled person:
        • Is no longer totally disabled
        • Has received maximum benefits from the contract
        • Becomes eligible for total disability under another group program




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WHEN YOU BECOME ELIGIBLE FOR MEDICARE
     If you and/or your covered dependents become eligible for Medicare, you can continue your health benefits under the plan.
     Under the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) and the Deficit Reduction Act of 1984 (DEFRA), if you
     or your spouse are over age 65, you or your spouse can designate this program, rather than Medicare, as primary coverage if
     the following conditions apply:
          • Your group employs 20 or more people
          • You are an active employee or your spouse, and
          • Your group notifies us that you or your spouse chooses the group’s coverage as primary, and pays the
               appropriate premium
     Under the Omnibus Budget Reconciliation Act of 1986 (OBRA), if you, your spouse or your dependent child or your
     dependent(s) are eligible for Medicare due to disability, you, your spouse or dependent child can designate this program as
     your primary coverage if:
          • Your group employs 100 or more people,
          • You are an active employee, and
          • Your group notifies us that you or your covered dependents become entitled to Medicare disability, and they pay the
               appropriate premium. If you designate Medicare as primary, your coverage under this group plan ends.




54                                                   www.empireblue.com
Your ERISA Rights
Empire feels it is important for every member to know his/her rights, so please review the following information.
THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974 (ERISA)
    If your group is subject to the Employee Retirement Income Security Act of 1974 (ERISA), you have certain rights and
    protections under ERISA. Under ERISA you are entitled to:
         • Examine, without charge, at the Plan Administrator’s office and other specified locations, all documents governing
              the plan, including insurance contracts and a copy of the latest annual report filed by the plan with the U.S.
              Department of Labor or Internal Revenue Service.
         • Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the plan,
              including insurance contracts and copies of the latest annual report and updated summary plan description. The Plan
              Administrator may make a reasonable charge for the copies.
         • Receive a summary of the plan’s annual financial report. The Plan Administrator is required by law to furnish each
              covered member with a copy of this summary annual report.
    Duties of the Plan Fiduciaries
    In addition to creating certain rights for covered members, ERISA imposes duties upon the people who are responsible for the
    operation of the plan. The people who operate the plan, called plan “fiduciaries,” have a duty to do so prudently and in the
    interest of you and other covered members. Your employment cannot be terminated, nor can you be discriminated against in
    any way, to prevent you from obtaining your benefits or exercising your rights under ERISA.
    Steps You Can Take to Enforce Your Rights
    ERISA specifically provides for circumstances under which you may take legal action as a covered member of the plan.
         • Under ERISA, you have the right to have your Plan Administrator review and reconsider your claim. If we deny a
             claim, wholly or partly, you may appeal our decision. You will be given written notice of why the claim was denied,
             and of your right to appeal the decision. You have 180 days to appeal our decision. You, or your authorized
             representative, may submit a written request for review. You have the right to obtain copies of documents relating to
             the decision without charge. You may ask for a review of pertinent documents, and you may also submit a written
             statement of issues and comments. The claim will be reviewed and we will make a decision within 60 days after the
             appeal is received. If special circumstances require an extension of time, the extension will not exceed 120 days after
             the appeal is received. The decision will be in writing, containing specific reasons for the decision. If your claim for
             benefits is ignored or denied, in whole or in part, you may file suit in a state or federal court. A lawsuit for benefits
             denied under this coverage can be filed no earlier than 60 days after the claim was filed, and no later than two years
             from the date that the services were received. In addition, if you disagree with the Plan Administrator’s decision or
             lack thereof concerning the qualified status of a medical child support order, you may file suit in federal court.
         • If you submit a written request for copies of any plan documents or other plan information to which you are entitled
             under ERISA and you do not receive them within 30 days, you may bring a civil action in a federal court. The court
             may require the Plan Administrator to pay up to $110 for each day’s delay until you receive the materials. This
             provision does not apply, however, if the materials were not sent to you for reasons beyond the control of the Plan
             Administrator.
         • In the unlikely event that the plan fiduciaries misuse the plan’s money, or if you are discriminated against for
             asserting your rights, you may seek assistance from the U.S. Department of Labor or you may file suit in a federal
             court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the
             person you have sued to pay these costs and fees. But if you lose, because, for example, the case is considered
             frivolous, you may have to pay all costs and fees.
    If you have any questions about your plan, contact your Plan Administrator or Member Services at 1-800-767-8672
    If you have any questions about your rights under ERISA, contact the regional office of the Employee Benefits Security
    Administration (EBSA), U.S. Department of Labor.
    U.S. Department of Labor
    Employee Benefits Security Administration (EBSA)
    Director, New York Regional Office
    33 Whitehall Street
    New York, NY 10004
    Telephone: 1-212-607-8600
    Fax: 1-212-607-8681
    Toll-Free: 1-866-444-3272




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ACCESS TO INFORMATION
     In addition to calling Member Services for claim and benefit information, you can contact them for:
          • The names, business addresses and official positions of Empire’s Board of Directors, officers, controlling persons,
               owners and partners
          • Empire’s most recently published annual financial statement
          • A consumer report of grievances filed with the Insurance Superintendent
          • Procedures that protect confidentiality of medical records and information
          • A copy of Empire’s Drug Formulary
          • A directory of participating providers
          • A description of our quality assurance program
          • A notice of specific individual provider affiliations with participating hospitals
          • Upon written request, specific written clinical criteria for determining if a procedure or test is medically necessary
     For Members Who Don’t Speak English
     Empire will help members who speak languages other than English ask questions and file grievances in their first language.
     When you call Member Services, the operator will link you to an interpreter in your preferred language, who can facilitate the
     discussion. HealthLine is also equipped to provide assistance in most languages.

CONFIDENTIALITY POLICY
     In recognition of the need for member privacy, and in compliance with federal and state laws and regulations, Empire has a
     policy on the confidentiality of member medical information.
          • Empire has in place and enforces appropriate safeguards to protect the confidentiality, security and integrity of
              member medical information which is used, disclosed, exchanged or transmitted orally, in writing or electronically.
          • Confidential member medical information is accessible only to those Empire employees and authorized third persons
              who need it to perform their jobs. All persons are required to comply with Empire policies and procedures and
              federal and state laws and regulation concerning the request for use, disclosure, release, security, storage and
              destruction of confidential member medical information.
          • Empire does not disclose our members’ nonpublic personal information to any of our affiliates or to nonaffiliated
              third parties, except as permitted by law to allow us to conduct our business.
          • Disclosure of confidential information to external vendors for purposes of payment or health care operations is made
              only in accordance with appropriate confidentiality agreements and contractual arrangements. Data shared with
              external entities for measurement purposes or research is released only in accordance with appropriate confidentiality
              agreements and contractual arrangements or in an aggregate form that does not allow for direct or indirect member
              identification
          • Identifiable personal health information is not shared with your employer, unless permitted or required by law.
          • Because Empire is not a provider of medical services, it generally does not maintain medical records created by your
              provider of service. If you require access to your provider’s medical records, please contact your provider to arrange
              access.
          • Empire contractually requires all of its network practitioners and providers to ensure the privacy and to protect the
              confidentiality of members’ medical information.
          • When you become covered under your Empire health benefit plan, you agree that Empire, or its designee, may use
              and/or disclose your confidential medical information for purposes of payment and healthcare operations as permitted
              or required by law or regulation. In addition, each Empire member agrees that any healthcare provider, healthcare
              payor or government agency shall furnish to Empire or its designee all records pertaining to medical history, services
              rendered, and payments made for use and/or disclosure by Empire to administer the terms of the health benefit plan.
          • You may request access to any other information that is maintained by or for Empire by calling Member Services to
              arrange access. You may request an amendment of records maintained by and for Empire, or you may request an
              accounting of disclosures as permitted by law.
          • Except as stated above and as may be permitted or required by law, Empire does not release confidential member
              medical information to anyone outside Empire without a specific “written authorization” to release, authorized by the
              member or member’s designee, which may be revoked at any time. The authorization must be signed and dated and
              must specify:
              − The information that can be disclosed and to whom
              − What the information will be used for, and
              − The time period for which the authorization applies.

     For additional information regarding the confidentiality of member medical information, please read Empire's Notice of
     Privacy Practices. Go to www.empireblue.com/nyc and click on "Privacy Notices" at the bottom of the homepage. If you would
     like a printed copy of this policy please call Empire Member Services at the toll-free number on your identification card.
     Please refer to the Notice of Privacy Practices section for more information.


56                                                     www.empireblue.com
Notice of Privacy Practices
                                 EFFECTIVE DATE: APRIL 14, 2003
          THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
                  DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
                                 PLEASE REVIEW IT CAREFULLY.
At Empire, we respect the confidentiality of your medical information and will protect that information in a responsible manner. We
have a comprehensive privacy program in place that meets the requirements of the Health Insurance Portability and Accountability
Act (HIPAA) Privacy Regulations, the government legislation that sets standards for the privacy of medical information. Empire
follows all state privacy laws to which we are subject that do not conflict with the HIPAA Privacy Regulations. However, if a state
privacy law conflicts with the HIPAA Privacy Regulations yet provides greater privacy rights or protections than the HIPAA
Privacy Regulations, we will follow that state law.
We must follow the privacy practices that are described in this notice while it is in effect. We reserve the right to change our privacy
practices and the terms of this notice at any time, as long as the changes are permitted by law. Before we make a significant change
to our privacy practices, we will change this notice and send the new one to our current subscribers. This new notice will be
effective for all medical information that we maintain, including medical information we created or received before the changes
were made.
Additionally, please know that Empire is required by law to maintain the privacy of your medical information and to give you this
notice regarding your rights, our privacy practices and legal duties concerning your medical information.

DEFINITION OF MEDICAL INFORMATION
    When Empire refers to medical information in this notice, we mean information that is individually identifiable health
    information. This includes demographic information collected from you or created or received by a healthcare provider, a
    health plan, your employer or a healthcare clearinghouse.
    This information relates to:
    (1) Your past, present or future physical or mental health or condition
    (2) The provision of health care to you, or
    (3) Past, present or future payments for the provision of healthcare to you.

USES AND DISCLOSURES OF MEDICAL INFORMATION
    This section provides you with a general description and examples of the ways your medical information is used and disclosed.
    Empire’s uses and disclosures are not limited to these examples.

    Treatment
    Your medical information may be used or disclosed to a physician or other healthcare provider in order for them to provide you
    with treatment.

    Payments
    Your medical information may be used or disclosed:
       • For billing, claims management and collections activities
       • To pay claims from physicians, hospitals and other providers for services delivered to you that are covered by your
           health plan
       • To determine your eligibility for benefits
       • To conduct risk adjustment activities
       • To coordinate benefits
       • To determine medical necessity
       • To conduct utilization review activities
       • To obtain premiums
       • To issue explanations of benefits to the person who subscribes to the health plan in which you participate
       • To a health care provider or entity so they can obtain payment or engage in payment activities




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     Health Care Operations
     Your medical information may be used and disclosed in connection with our healthcare operations, including:
        • Underwriting, premium rating and other activities relating to the creation, renewal or replacement of benefit coverage.
        • Case management and care coordination.
        • Contacting healthcare providers and patients with information about treatment alternatives, disease management or
             wellness programs and related functions that do not include treatment.
        • Population-based activities relating to improving health or reducing health care costs.
        • Quality assessment and improvement activities and protocol development.
        • Reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider
             performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
        • Conducting or arranging for medical review, legal services, auditing, and fraud and abuse detection and
             compliance programs.
        • Business planning and development, such as formulary development and administration.
        • Business management and general administrative activities, including management activities relating to privacy,
             customer service and resolution of internal grievances.
     Additional Disclosures
     Your medical information may be disclosed:
        • To another entity that has a relationship with you for their health care operations relating to quality assessment and
            improvement activities, reviewing the competence or qualifications of healthcare professionals, or detecting or
            preventing healthcare fraud and abuse.
        • To other persons or entities that assist us in conducting our payment, health care operations and business activities.
            We will not disclose your medical information to those persons or entities unless they agree to keep it protected.
     Health-Related Services
     Your medical information may be used to send you appointment reminders, or to communicate with you to encourage you to
     purchase or use a health-related product or service (or payment for such product or service), that is provided by, or included in,
     an Empire health plan.
     This includes communications about: the entities participating in a healthcare provider network or health plan network;
     replacement of, or enhancements to, a health plan; and health-related products or services available only to a health plan
     enrollee that add value to, but are not part of, a benefit plan, for purposes of treatment, case management or care coordination,
     or to direct or recommend alternative treatments, therapies, healthcare providers or settings of care.

     To Your Family and Friends
     Your medical information may be disclosed to a family member, friend or other person to the extent necessary to help with
     your healthcare or with payment for your healthcare.
     Your name, location and general condition or death may be used or disclosed to notify or assist in the notification of (including
     identifying or locating) a person involved in your care.
     We will provide you with an opportunity to object to such uses or disclosures, unless, based on professional judgment, we may
     reasonably infer from the circumstances that you do not object to such uses and disclosures.
     If you are not present, or in the event of your incapacity or an emergency, we will use our professional judgment in deciding
     whether disclosing your medical information would be in your best interest.

     If You Are a Member of a Group Health Plan
     Your medical information, and the medical information of others enrolled in your group health plan, may be disclosed to your
     employer or the organization that sponsors your group health plan (the “plan sponsor”) in order to permit the plan sponsor to
     perform plan administration functions. Please see your plan documents for an explanation of these limited uses
     and disclosures.
     Summary information about the enrollees in your group health plan may also be disclosed to the plan sponsor so they may
     obtain premium bids for health insurance coverage, or in order to decide whether to modify, amend or terminate your group
     health plan. The information we may disclose summarizes claims history and expenses or types of claims experienced by the
     enrollees in your group health plan. This summary information will be stripped of demographic information, but the plan
     sponsor may still be able to identify you or other enrollees.

     Disaster Relief
     We may use or disclose your medical information to a public or private entity authorized by its charter or by law to assist in
     disaster relief efforts.



58                                                      www.empireblue.com
For the Public Benefit
Your medical information may be used or disclosed as authorized by law for the following purposes:
    • As required by law
    • For public health activities, including disease and vital statistic reporting, child abuse reporting, FDA oversight and to
        employers regarding work-related illness or injury
    • To report adult abuse, neglect or domestic violence
    • To health oversight agencies
    • In response to court and administrative orders and other lawful processes
    • To law enforcement officials pursuant to subpoenas and other lawful processes concerning crime victims, suspicious
        deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect
        or other person
    • To coroners, medical examiners and funeral directors
    • To organ procurement organizations
    • To avert a serious threat to health or safety
    • In connection with certain research activities
    • To the military and to federal officials for lawful intelligence, counterintelligence and national security activities
    • To correctional institutions regarding inmates
    • As authorized by state workers’ compensation law
Marketing
Your medical information may be used or disclosed to encourage you to purchase or use a product or service by face-to-face
communication by us or for us to provide you with promotional gifts of nominal value.

Fundraising
Your demographic information and the dates of healthcare services provided to you may be used in order to contact you for
fundraising. We may disclose information to a business associate or foundation to assist us in our fundraising activities. We
will provide you with fundraising materials and a description of how you may opt out of receiving future fundraising
communications.

Your Written Authorization Is Required
Other uses and disclosures of your medical information that are not described above will only be made with your written
authorization. You may give us written authorization to use or to disclose your medical information to anyone for any purpose.
You may revoke your authorization at any time. However, your revocation will not affect any use or disclosure that you
permitted prior to your revocation.

Your Individual Rights
Access to Your Information: You have the right to inspect or obtain a copy of the medical information about you that is
contained in a “designated record set” except for psychotherapy notes and certain other information. A “designated record set”
generally contains medical and billing records as well as other records that are maintained by or for us, or used by or for us to
make decisions about you. We may ask you to submit your request in writing and to provide us with the specific information
we need in order to fulfill your request. We reserve the right to charge a reasonable fee for the cost of producing and mailing
the copies to you. In certain situations, we may deny your request to inspect or obtain a copy of the requested information. If
we deny your request, we will notify you in writing and may provide you with an opportunity to have the denial reviewed.
Accounting Disclosures
You have the right to receive a list of instances in which we or our business associates disclosed your medical information for
purposes other than treatment, payment, health care operations or those authorized by you as well as for certain other activities
that occurred up to six years before the date of your request. However, you will not be able to obtain a list of disclosure
instances that occurred prior to April 14, 2003; the date this notice is effective. Any list we send you will include the date(s) of
the disclosure, to whom it was made, their address, if known, a brief description of the information disclosed and the purpose
of the disclosure. If you request this accounting list more than once in a 12-month period, we may charge you a reasonable
administration fee for these additional requests.

Restrictions on Use or Disclosure
You have the right to request that we restrict the use or disclosure of your medical information in connection with treatment,
payment and health care operations. You also have the right to request that we restrict disclosures to persons involved in your
health care or payment for your health care. We may ask you to submit your request in writing. We will review your request,
but we are not required to comply with it.



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     Confidential Communications
     You have the right to request that we communicate with you about your medical information by a different means or location.
     You must make your request in writing and state that the information could endanger you if it is not communicated by a
     different means or location. We must accommodate your request if it is reasonable and specifies the new means or location of
     contact. It must also allow us to collect premiums and pay claims. This includes issuing explanations of benefits to the
     subscriber of the health plan in which you participate.
     An explanation of benefits issued to the subscriber about the subscriber or others covered by the health plan in which you
     participate, may contain sufficient information to reveal that you obtained health care for which we paid, even though we
     communicated with you in the confidential manner you requested. Once your request for confidential communications is in
     effect, all of your medical information will be communicated in accordance with your instructions.

     Amending Your Medical Information
     If you believe that the medical information contained in your “designated record set” is not correct or complete, you have the
     right to request that we amend it. We may require your request be in writing and that it explains why the information should be
     changed. If we make the amendment, we will notify you. In addition, if we make the change, we will make reasonable efforts
     to inform others, including people you name, of the amendment and to include the changes in any future disclosures of that
     information.
     If your request is denied, you will be notified in writing of the reason for the denial and the letter will explain how to file a
     written statement of disagreement. Empire has the option to rebut your statement. You have the right to ask that your original
     request, our denial and your statement of disagreement be included with any future disclosures of your information.

     Additional Copies, Questions or Complaints
     Requests for Additional Copies and Questions Regarding Privacy and Individual Rights:
         • You may request a copy of our notice at any time.
         • If you view this notice on our website or receive it by e-mail, you are also entitled to receive it in written form.
         • You may request more detailed information about your rights and privacy protections or learn how to exercise those
              individual rights as described in this notice.
     Please contact Member Services at the phone number listed on the back of your member identification card or write to us at
     P.O. Box 1407, Church Street Station, New York, NY 10008-1407.

     Complaints
     If you believe that Empire has violated your privacy rights, write to our Privacy Office at P.O. Box 1407, Church Street
     Station, New York, NY 10008-1407 or call Member Services at the phone number listed on the back of your member
     identification card.
     You also may file a complaint with the Secretary of the U.S. Department of Health and Human Services. Complaints filed
     directly with the Secretary must: (1) be in writing; (2) contain the name of the entity against which the complaint is lodged; (3)
     describe the relevant problems; and (4) be filed within 180 days of the time you became or should have become aware of the
     problem. We will provide you with this address upon request. We will not retaliate in any way if you choose to file a complaint
     with us or with the U.S. Department of Health and Human Services. We support your right to the privacy of your medical
     information.




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HIPAA Privacy Requirements

EMPLOYER/SPONSOR
      1.   Under the requirements of the Health Insurance Portability and Accountability Act of 1996 and its implementing
           privacy and security regulations (45 C.F.R. Parts 160 and 164), referred to as HIPAA, the Employer/Sponsor of a
           Group Health Plan (the “Plan”) may obtain and use a member’s summary information1 for purposes of obtaining
           premium bids, to modify, amend or terminate the Plan, and for enrollment and eligibility determinations.
           Under the requirements of HIPAA, the Employer/Sponsor may obtain and use a member’s Protected Health
           Information, including electronic protected health information (PHI)2, for purposes of Plan Administration. To the
           extent the Employer/Sponsor requires PHI, and prior to receiving PHI, the Employer/Sponsor shall certify to the
           Plan that the Plan Documents meet the requirements of HIPAA (as described below).

EMPLOYER/SPONSOR OBLIGATIONS
      2.   The Employer/Sponsor agrees to comply with the following in order to obtain PHI about members for the
           permissible limited uses or disclosures for the Plan administration functions it performs.

      Purpose of Disclosure to Employer/Sponsor
           (a) The Plan and any health insurer or HMO will disclose members’ PHI to the Employer/Sponsor only to permit
               the Employer/Sponsor to carry out Plan administration functions for the Plan not inconsistent with the
               requirements of HIPAA. Any disclosure to and use by the Employer/Sponsor of members’ PHI will be subject
               to and consistent with the provisions of this section.
           (b) Neither the Plan nor any health insurance issuer or HMO will disclose members’ PHI to the Employer/Sponsor unless
               the disclosures are explained in the Notice of Privacy Practices distributed to the members.
           (c) Neither the Plan nor any health insurance issuer or HMO will disclose members’ PHI to the Employer/Sponsor for
               the purpose of employment-related actions or decisions or in connection with any other benefit or employee benefit
               Plan of the Employer/Sponsor.

      Restrictions on Plan Sponsor’s Use and Disclosure of PHI
      3. (a) The Employer/Sponsor will neither use nor further disclose members’ PHI, except as permitted or required by
              the Plan Documents, as amended or required by law.
         (b) The Employer/Sponsor will implement administrative, physical, and technical safeguards that reasonably and
              appropriately protect the confidentiality, integrity and availability of PHI.
         (c) The Employer/Sponsor will ensure that any agent, including any subcontractor, to whom it provides members’ PHI,
              agrees to these restrictions and conditions, including implementing reasonable and appropriate security measures in
              the Plan Documents, with respect to members’ PHI.
         (d) The Employer/Sponsor will not use or disclose members’ PHI for employment-related actions or decisions or in
              connection with any other benefit or employee benefit Plan of the Employer/Sponsor.
         (e) The Employer/Sponsor will report to the Plan any use or disclosure or security incident of members’ PHI that is
              inconsistent with the allowed uses and disclosures promptly upon learning of such inconsistent use or disclosure.
         (f) The Employer/Sponsor will make PHI available to the member who is the subject of the information in accordance
              with 45 Code of Federal Regulations § 164.524, Access of Individual to PHI.
         (g) The Employer/Sponsor will make members’ PHI available for amendment, and will on notice amend members’ PHI,
              in accordance with 45 Code of Federal Regulations § 164.526, Amendment of PHI.
         (h) The Employer/Sponsor will track disclosures it may make of members’ PHI so that it can make available the
              information required for the Plan to provide an accounting of disclosures in accordance with 45 Code of Federal
              Regulations § 164.528, Accounting of Disclosures of PHI.
         (i) The Employer/Sponsor will make its internal practices, books, and records, relating to its use and disclosure of
              members’ PHI, to the Plan and to the U.S. Department of Health and Human Services to determine compliance with
              45 Code of Federal Regulations Parts 160-64.


1
    Summary information summarizes the claims history, claims expenses, or types of claims of individuals covered under a group health plan, and from
    which individual identifiers have been removed.
2
    Health information that is received, created, maintained or transmitted in electronic form or in any other form or medium by a health plan, insurer or
    HMO that identifies the individual or can be used to identify the individual and that relates to an individual’s physical or mental health or condition,
    including information related to an individual’s care or the payment for such care.



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         (j) The Employer/Sponsor will, if feasible, return or destroy all member PHI, in whatever form or medium (including in
             any electronic medium under the Employer’s/ Sponsor’s custody or control), received from the Plan that the
             Employer/Sponsor still maintains, including all copies of and any data or compilations derived from and allowing
             identification of any Participant who is the subject of the PHI, when the members’ PHI is no longer needed for the
             Plan administration functions for which the disclosure was made. If it is not feasible to return or destroy all members’
             PHI, the Employer/Sponsor will limit the use or disclosure of any member PHI it cannot feasibly return or destroy to
             those purposes that make the return or destruction of the information infeasible.
     Adequate Separation between the Employer/Sponsor and the Plan
     4. (a) The Employer/Sponsor will ensure the adequate separation between employees and the Plan, supported by
            reasonable and appropriate security measures.
            1) All employees or classes of employees or other workforce members under the control of the Employer/Sponsor
                 may be given access to or may receive members’ PHI relating to payment under or health care operations of the
                 Plan, or other matters pertaining to the Plan in the ordinary course of business.
            2) The employees, classes of employees or other workforce members identified above will have access to
                 members’ PHI only to perform the Plan administration functions that the Employer/Sponsor provides for
                 the Plan.
        (b) The employees, classes of employees or other workforce members identified above will be subject to disciplinary
            action and sanctions, including termination of employment or affiliation with the Employer/Sponsor, for any use or
            disclosure or security incident of members’ PHI in breach or violation of or noncompliance with these provisions of
            the Plan Documents. The Employer/Sponsor will promptly report such breach, violation or noncompliance to the
            Plan, as required by paragraph 3(e), and will cooperate with the Plan to correct the breach, violation or
            noncompliance, to impose appropriate disciplinary action or sanctions on each employee or other workforce member
            causing the breach, violation or noncompliance, and to mitigate any deleterious effect of the breach, violation or
            noncompliance on any Participant, the privacy or security of whose PHI may have been compromised by the breach,
            violation or noncompliance.




62                                                    www.empireblue.com
Definitions
Refer to these definitions to help you better understand your Empire EPO coverage. Need more help? Additional terms and
definitions can be viewed at www.empireblue.com/nyc.

    Adverse Determination
    A communication from Empire’s Medical Management that reduces or denies benefits.

    Ambulatory Surgery
    See “same-day surgery.”

    Authorized Services
    See “precertified services.”

    BlueCard® Program
    The BlueCard Program helps reduce your costs when you obtain emergency care outside of the geographic area served by
    Empire from a provider who participates with another Blue Cross and/or Blue Shield Plan (“local Blue Plan”). Just show your
    Empire ID card to a participating provider and comply with the other terms in the certificate of coverage when receiving these
    services.
    When you obtain healthcare through the BlueCard Program, the portion of your claim that you are responsible for (“member
    liability”) is, in most instances, based on the lower of the following:
          • the billed amount that the participating provider actually charges for covered services, or
          • the negotiated price that the local Blue Plan passes on to Empire.
    Here’s an example of a negotiated price and how it benefits you:
    A provider’s standard charge is $100, but he/she has a negotiated price of $80 with the local Blue Plan. If your coinsurance is
    20%, you pay $16 (20% of $80) instead of $20 (20% of $100).
    The negotiated price may reflect:
          • a simple discount from the provider’s usual charges, which is the amount that would be reimbursed by the local
               Blue Plan;
          • an estimated price that has been adjusted to reflect expected settlements, withholds, any other contingent payment
               arrangements and any non-claim transactions with the provider; or
          • the provider’s billed charges adjusted to reflect average expected savings that the local Blue Plan passes on to Empire.
               If the negotiated price reflects average savings, it may vary (more or less) from the actual price than it would if it
               reflected the estimated price.
    Plans using the estimated price or average savings methods may adjust their prices in the future to ensure appropriate pricing.
    However, the amount you pay is considered the final price.
    A small number of states have laws that require that your member liability be calculated based on a method that does not reflect
    all savings realized, or expected to be realized, by the local Blue Plan on your claim, or that requires that a surcharge be added
    to your member liability. If you receive covered healthcare services in any of these states, member liability will be calculated
    using the state’s statutory methods that are in effect at the time you receive care.
    If you have any questions about the BlueCard Program, contact Member Services.

    BlueCard® PPO Program
    Nationwide, Blue Cross and Blue Shield plans have established Preferred Provider Organization (PPO) networks of physicians,
    hospitals and other healthcare providers. As an EPO member, you have access to these networks through the BlueCard PPO
    Program to receive in-network benefits for covered services. By presenting your Empire I.D. card to a provider participating in
    the BlueCard PPO Program, you receive the same benefits as you would receive from an Empire network provider. The
    suitcase logo on your I.D. card indicates that you are a member of the BlueCard PPO Program. Call 1-800-810-BLUE (2583)
    or visit www.bcbs.com to locate participating providers.




                                                      www.empireblue.com                                                           63
     BlueCard® Worldwide Program
     The BlueCard Worldwide program provides hospital and professional coverage through an international network of healthcare
     providers. With this program, you’re assured of receiving care from licensed healthcare professionals. The program also
     assures that at least one staff member at the hospital will speak English, or the program will provide translation assistance.
     Here’s how to use BlueCard Worldwide:
         • Call 1-804-673-1177, 24 hours a day, seven days a week, for the names of participating doctors and hospitals. Outside
               the U.S., you may use this number by dialing an AT&T Direct®1 Access Number.
         • Show your Empire ID card at the hospital. If you’re admitted, you will only have to pay for expenses not covered by
               your contract, such as co-payments, coinsurance, deductibles and personal items. Remember to call Empire within 24
               hours, or as soon as reasonably possible.
         • If you receive outpatient hospital care or care from a doctor in the BlueCard Worldwide Program, pay the bill at the
               time of treatment. When you return home, submit an international claim form and attach the bill. This claim form is
               available from the healthcare provider or by calling the BlueCard Worldwide Program. Mail the claim to the address
               on the form. You will receive reimbursement less any co-payment and amount above the allowed amount.
     Co-payment
     The fee you pay for office visits and certain covered services when you use in-network providers. The plan then pays 100% of
     remaining covered expenses.
     Covered Services
     The services for which Empire provides benefits under the terms of your contract. For example, Empire’s EPO covers one in-
     network annual physical exam.
     Hospital/Facility
     A fully licensed acute-care general facility that has all of the following on its own premises:
         • A broad scope of major surgical, medical, therapeutic and diagnostic services available at all times to treat almost all
               illnesses, accidents and emergencies
         • 24-hour general nursing service with registered nurses who are on duty and present in the hospital at all times
         • A fully-staffed operating room suitable for major surgery, together with anesthesia service and equipment. The
               hospital must perform major surgery frequently enough to maintain a high level of expertise with respect to such
               surgery in order to ensure quality care
         • Assigned emergency personnel and a “crash cart” to treat cardiac arrest and other medical emergencies
         • Diagnostic radiology facilities
         • A pathology laboratory
         • An organized medical staff of licensed doctors
     For pregnancy and childbirth services, the definition of “hospital” includes any birthing center that has a participation
     agreement with either Empire or another Blue Cross and/or Blue Shield plan.

     For physical therapy purposes, the definition of a “hospital” may include a rehabilitation facility either approved by Empire or
     participating with Empire or another Blue Cross and/or Blue Shield plan other than specified above.

     For kidney dialysis treatment, a facility in New York State qualifies for in-network benefits if the facility has an operating
     certificate issued by the New York State Department of Health, and participates with Empire or another Blue Cross and/or Blue
     Shield plan. In other states, the facility must participate with another Blue Cross and/or Blue Shield plan and be certified by the
     state using criteria similar to New York’s. Out-of-network benefits will be paid only for non-participating facilities that have an
     appropriate operating certificate.
     For behavioral healthcare purposes, the definition of “hospital” may include a facility that has an operating certificate issued by
     the Commissioner of Mental Health under Article 31 of the New York Mental Hygiene Law; a facility operated by the Office
     of Mental Health; or a facility that has a participation agreement with Empire to provide mental and behavioral healthcare
     services. For alcohol and/or substance abuse received out-of-network, a facility in New York State must be certified by the
     Office of Alcoholism and Substance Abuse Services. A facility outside of New York State must be approved by the Joint
     Commission on the Accreditation of Healthcare Organizations.
     For certain specified benefits, the definition of a “hospital” or “facility” may include a hospital, hospital department or facility
     that has a special agreement with Empire.




64                                                      www.empireblue.com
Empire’s EPO does not recognize the following facilities as hospitals: nursing or convalescent homes and institutions;
rehabilitation facilities (except as noted above); institutions primarily for rest or for the aged; spas; sanitariums; infirmaries at
schools, colleges or camps; and any institution primarily for the treatment of drug addiction, alcoholism or mental health care.
In-Network Benefits
Benefits for covered services delivered by in-network providers and suppliers. Services provided must fall within the scope of
their individual professional licenses.

In-Network Provider/Supplier
A doctor, other professional provider, or durable medical equipment, home health care or home infusion supplier who:
    • Is in Empire’s PPO network
    • Is in the PPO network of another Blue Cross and/or Blue Shield plan
    • Has a negotiated rate arrangement with another Blue Cross and/or Blue Shield plan that does not have a PPO network

Itemized Bill
A bill from a provider, hospital or ambulance service that gives information that Empire needs to settle your claim. Provider
and hospital bills will contain the patient’s name, diagnosis, and date and charge for each service performed. A provider bill
will also have the provider’s name and address and descriptions of each service, while a hospital bill will have the subscriber’s
name and address, the patient’s date of birth and the plan holder’s Empire identification number. Ambulance bills will include
the patient’s full name and address, date and reason for service, total mileage traveled, and charges.

Medically Necessary
Services, supplies or equipment provided by a hospital or other provider of health services that are:
      • Consistent with the symptoms or diagnosis and treatment of the patient’s condition, illness or injury,
      • In accordance with standards of good medical practice,
      • Not solely for the convenience of the patient, the family or the provider,
      • Not primarily custodial, and
      • The most appropriate level of service that can be safely provided to the patient.
The fact that a network provider may have prescribed, recommended or approved a service, supply or equipment does not, in
itself, make it medically necessary.

Non-Participating Hospital/Facility
A hospital or facility that does not have a participation agreement with Empire or another Blue Cross and/or Blue Shield plan
to provide services to persons covered under Empire’s EPO contract. Or, a hospital or facility that does not accept negotiated
rate arrangements as payment in full in a plan area without a PPO network.

Operating Area
Empire operates in the following 28 eastern New York State counties: Albany, Bronx, Clinton, Columbia, Delaware, Dutchess,
Essex, Fulton, Greene, Kings, Montgomery, Nassau, New York, Orange, Putnam, Queens, Rensselaer, Richmond, Rockland,
Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington, Westchester.

Out-of-Network Providers/Suppliers
A doctor, other professional provider, or durable medical equipment, home health care or home infusion supplier who:
    • Is not in Empire’s PPO network
    • Is not in the PPO network of another Blue Cross and/or Blue Shield plan
    • Does not have a negotiated rate with another Blue Cross and/or Blue Shield plan

Outpatient Surgery
See “same-day surgery.”




                                                    www.empireblue.com                                                              65
     Participating Hospital/Facility
     A hospital or facility that:
         • Is in Empire’s network
         • Is in the PPO network of another Blue Cross and/or Blue Shield plan
         • Has a negotiated rate arrangement with another Blue Cross and/or Blue Shield plan that does not have a PPO network

     Plan Administrator
     The person who has certain authority concerning the health plans, such as plan management, including deciding questions of
     eligibility for participation, and/or the administration of plan assets. Empire is not the Plan Administrator. To identify your
     Plan Administrator, contact your employer or health plan sponsor.

     Precertified Services
     Services that must be coordinated and approved by Empire’s Medical Management or Behavioral Healthcare Management
     Programs to be fully covered by your plan. For example, failure to precertify planned inpatient surgery may result in reduction
     or denial of benefits.

     Provider
     A hospital or facility (as defined earlier in this section), or other appropriately licensed or certified professional healthcare
     practitioner. Empire will pay benefits only for covered services within the scope of the practitioner’s license.
     For behavioral healthcare purposes, “provider” includes care from psychiatrists, psychologists or certified social workers (with
     three or more years of post-degree supervised experience), providing psychiatric or psychological services within the scope of
     their practice, including the diagnosis and treatment of mental and behavioral disorders.
     For maternity care purposes, “provider” includes a certified nurse-midwife affiliated with or practicing in conjunction with a
     licensed facility and whose services are provided under qualified medical direction.

     Same-Day Surgery
     Same-day, ambulatory or outpatient surgery is surgery that does not require an overnight stay in a hospital.

     Treatment Maximums
     Maximum number of treatments or visits for certain conditions.




66                                                     www.empireblue.com
HealthLine Recorded Topics
Following is a list of some of our most popular health-related audiotape topics that you can listen to free of charge, 24 hours a day,
seven days a week, when you call HealthLine at 1-877-TALK-2RN (825-5276). See the Health Management section for more
information on HealthLine and instructions on how to listen to the tapes. These are our most requested audiotapes; there are more
than 1,100 available. If you do not see the topic that interests you, just ask one of the HealthLine nurses.

Aging                                                                Digestive System (continued)
7805     Alzheimer’s Disease                                         4422      Diverticulosis and Diverticulitis
7845     Impotence in Older Men                                      5404      Gallbladder Disease
7878     Sleep Problems                                              5406      Gastroenteritis
                                                                     4415      Heartburn and the Digestive System
Alcohol Problems                                                     4416      Hemorrhoids
4131     Alcoholism – Causes                                         5411      Intestinal Gas
4133     Alcoholism - The Disease of Denial                          4419      Irritable Bowel Syndrome
                                                                     5414      Pancreatitis
Arthritis                                                            5416      Rectal Bleeding
4172     Arthritis Or Rheumatism?                                    4421      Ulcers – Overview
4171     Arthritis Symptoms
4175     Osteoarthritis                                              Ear, Nose and Throat
                                                                     4453      Ear Wax (Cerumen)
Back and Neck                                                        4456      Ringing in the Ear – Causes
4192     Back Pain – Causes                                          4457      Sinus Problems
4193     Exercises for the Desk Bound
4199     Neck Pain                                                   Eyes and Vision
                                                                     4512      Double Vision
Blood and Circulatory                                                4513      Eye Symptoms Demanding Immediate Attention
4211     Anemia                                                      4517      Spots and Floaters
6104     Aneurysms
                                                                     Hormonal Disorders
Bones, Joints and Muscles                                            4701      Hyperthyroidism (Overactive Thyroid)
4239     Gout                                                        4702      Hypothyroidism (Underactive Thyroid
Cancer                                                               Infectious Diseases
6417     Colon Cancer                                                4735      Fifth Disease
6429     Leukemia – Chronic                                          4724      Lyme Disease
6481     Pancreatic Cancer
6453     Seven Warning Signs of Cancer                               Men’s Health
6459     Stomach Cancer                                              4764      Prostate Problems
6465     Throat Cancer
6486     Thyroid Cancer                                              Mental and Emotional Health
                                                                     6707      Anxiety
Cardiovascular Health                                                6717      Depression and its Symptoms
6101     Abnormal Heartbeat                                          6720      Exhibitionism
6113     Chest Pain (Other Than Angina)                              6725      Grief and Loss
6116     Cholesterol - “Good” and “Bad”                              6733      Kleptomania
6119     Congestive Heart Failure                                    6735      Letting Go of Resentment
6129     Early Warning of Heart Attack                               6737      Manic or Bipolar Depression
6144     High Blood Pressure and Heart Disease                       6744      Narcissism
6170     Triglycerides                                               6745      Nervous Breakdown
                                                                     6748      Obsession and Compulsion
Common Illnesses                                                     6749      Panic Attacks
4332     Eczema                                                      6763      Schizophrenia
                                                                     6773      Suicide
Digestive System                                                     6777      Voyeurism
5400     Anal Fissure and Fistulas
4411     Colitis                                                     Respiratory Problems
4412     Constipation in the Digestive System                        4933      Chronic Cough - A Significant Respiratory Problem
5402     Crohn’s Disease                                             4934      Emphysema
4413     Diarrhea in the Digestive System




                                                        www.empireblue.com                                                           67
Sexually Transmitted Diseases                             Weight Control
4951   Chlamydia                                          6911    Choosing a Commercial Diet Program
4953   Herpes                                             6981    Teaching Your Body to Burn More Calories
4955   Syphilis
                                                          Women’s Health
Skin Health                                               7134    Hot Flashes
4975   Psoriasis                                          7135    Hysterectomy
                                                          7144    Menopause Problems?
Sports Medicine                                           5313    Sexual Response in Women
7462   Tendonitis                                         7191    Yeast Infections
Stress and How to Cope                                    Other Categories:
5131   10 Stress Busters You Can Do                       Allergies
5132   Burnout - Is It Happening to You?                  Brain and Nervous System
5133   Facing Financial Troubles                          Child Health and Development
5134   How Friends Buffer Stress                          Cosmetic and Reconstructive Surgery
5135   Mental Exercises For Stress Management             Dental Health
5138   Stress – What Is It?                               Diabetes
                                                          Drug Abuse
Symptoms                                                  Eating Disorders
6127   Dizziness as a Symptom                             Exercise and Fitness
                                                          Family Planning
Teenage Concerns                                          Foot Care
5227   Homosexuality                                      General Health
5228   Masturbation                                       Genetic Disorders and Birth Defects
                                                          Headaches
Tests and Examinations                                    Health Quizzes
6418   Colonoscopy                                        Hearing
6131   Echocardiography                                   HIV Infection/AIDS
5241   Endoscopic Retrograde                              Medications
       Cholangiopancreatography (ERCP)                    Neurology
7465   Thyroid Tests                                      Newborn Care
                                                          Nutrition
Urinary and Genital Systems                               Parenting and Family Life
5261   Bladder Stones                                     Personal Safety
5262   Blood in Urine                                     Pregnancy and Childbirth
5267   Women and Urinary Infections                       Preparing for Emergencies
                                                          Surgery




68                                              www.empireblue.com

				
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